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Deficiency Records for Manor of Fond Du Lac
A list of the most recent deficiencies for Manor 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 Manor 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-26 | 2024-05-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-26 | 2024-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-26 | 2024-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-27 | 2024-04-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-26 | 2024-04-20 | N |
| 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 | 2024-03-27 | 2024-04-19 | N |
| Post nurse staffing information every day. | Health | 2024-03-27 | 2024-04-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-26 | 2024-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-26 | 2024-04-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-27 | 2024-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-27 | 2024-04-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-27 | 2024-04-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-26 | 2024-04-17 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-03-27 | 2024-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-27 | 2024-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-27 | 2024-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-03-29 | 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 | 2024-03-26 | 2024-03-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-03-26 | 2024-03-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-26 | 2024-03-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-26 | 2024-03-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-27 | 2024-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-27 | 2024-03-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-27 | 2024-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-07 | 2023-04-07 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-07 | 2023-04-07 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-03-07 | 2023-04-07 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-07 | 2023-04-07 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-07 | 2023-04-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-07 | 2023-04-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-07 | 2023-04-07 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-07 | 2023-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-04-07 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-07 | 2023-04-07 | N |
| 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 | 2023-03-07 | 2023-04-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-07 | 2023-04-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-07 | 2023-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-07 | 2023-04-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-07 | 2023-04-07 | Y |
| 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 | 2023-03-07 | 2023-04-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-07 | 2023-04-07 | 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 | 2023-03-07 | 2023-03-29 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-03-07 | 2023-03-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-07 | 2023-03-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-03-07 | 2023-03-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-07 | 2023-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-07 | 2023-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-07 | 2023-03-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-05 | 2023-01-05 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-01-26 | 2022-03-08 | N |
| 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 | 2022-01-26 | 2022-03-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-26 | 2022-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-26 | 2022-03-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-26 | 2022-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-26 | 2022-03-08 | 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 | 2022-01-26 | 2022-03-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-01-26 | 2022-03-08 | N |
| Provide or obtain dental services for each resident. | Health | 2022-01-26 | 2022-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-26 | 2022-03-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-26 | 2022-03-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-25 | 2022-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-25 | 2022-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-25 | 2022-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-25 | 2022-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-25 | 2022-01-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-25 | 2022-01-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-25 | 2022-01-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-25 | 2022-01-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-25 | 2022-01-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-01-25 | 2022-01-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-26 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-26 | Not Fixed | N |
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