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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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-09-30 | N |
| 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 |
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