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Deficiency Records for Edenbrook of Fond Du Lac

A list of the most recent deficiencies for Edenbrook of Fond Du Lac. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Edenbrook of Fond Du Lac. 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?
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-05-14 2024-09-25 N
Have an enclosure around a vertical opening shaft. Fire Safety 2024-05-14 2024-08-30 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-05-14 2024-06-27 N
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 2024-05-14 2024-06-27 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2024-05-15 2024-06-17 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-05-15 2024-06-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-15 2024-06-17 N
Provide and implement an infection prevention and control program. Health 2024-05-15 2024-06-17 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-05-15 2024-06-07 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-04-19 2023-05-18 N
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 2023-04-18 2023-05-18 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-04-18 2023-05-18 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-04-18 2023-05-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-04-19 2023-05-15 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-04-18 2023-05-15 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-04-18 2023-05-10 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-04-18 2023-05-09 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-04-18 2023-05-09 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-04-18 2023-05-09 N
Provide properly protected cooking facilities. Fire Safety 2023-04-18 2023-05-08 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-04-18 2023-05-08 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-11-02 2022-11-30 Y
Provide and implement an infection prevention and control program. Health 2022-11-02 2022-11-30 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 2022-11-02 2022-11-30 Y
Have exits that are accessible at all times. Fire Safety 2022-04-21 2022-06-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-04-20 2022-05-19 N
Provide and implement an infection prevention and control program. Health 2022-04-20 2022-05-19 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-04-21 2022-05-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-04-21 2022-05-19 N
Develop a communication plan. Fire Safety 2022-04-21 2022-05-13 N
Provide properly protected cooking facilities. Fire Safety 2022-04-21 2022-05-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-04-21 2022-05-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-04-21 2022-05-13 N
Provide a written emergency evacuation plan. Fire Safety 2022-04-21 2022-05-13 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2022-04-21 2022-05-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-05-14 Not Fixed N

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