A list of the most recent deficiencies for Waterfall Health of Wausau. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-07 | 2023-10-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-12 | 2023-09-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-12 | 2023-09-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-09 | 2023-09-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-09 | 2023-09-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-09 | 2023-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-09-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-09 | 2023-09-07 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-09 | 2023-09-07 | N |
| Keep all essential equipment working safely. | Health | 2023-08-09 | 2023-09-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-09 | 2023-09-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-09 | 2023-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-09-07 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-07 | 2023-09-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-07 | 2023-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-07 | 2023-09-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-07 | 2023-09-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-05-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-26 | 2023-05-26 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-26 | 2023-05-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2023-01-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-11 | 2022-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-26 | 2022-08-12 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-25 | 2022-08-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-25 | 2022-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-25 | 2022-08-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-25 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-25 | 2022-08-12 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-21 | 2022-07-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-26 | 2022-07-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-26 | 2022-07-18 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-08 | 2022-04-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-08 | 2022-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-08 | 2022-04-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-08 | 2022-04-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-08 | 2022-04-06 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-08 | 2022-04-06 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-03-08 | 2022-04-06 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-08 | 2022-04-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-08 | 2022-04-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-08 | 2022-04-06 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-08 | 2022-04-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-08 | 2022-04-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-08 | 2022-04-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-08 | 2022-04-06 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-08 | 2022-04-06 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-08 | 2022-04-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-17 | 2021-12-03 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-05 | 2021-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-11 | 2021-09-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-05-12 | 2021-06-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-12 | 2021-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-12 | 2021-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-12 | 2021-06-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-12 | 2021-06-09 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-12 | 2021-06-09 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-12 | 2021-06-09 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-12 | 2021-06-09 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-05-12 | 2021-06-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-12 | 2021-06-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-12 | 2021-06-09 | N |
