A list of the most recent deficiencies for Fondulac Rehabilitation and Hcc. 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 properly located and lighted "Exit" signs. | Fire Safety | 2023-08-01 | 2023-08-31 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-08-04 | 2023-08-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-15 | 2023-08-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-15 | 2023-08-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-15 | 2023-08-25 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-08-04 | 2023-08-25 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-08-04 | 2023-08-25 | 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 | 2023-08-04 | 2023-08-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-04 | 2023-08-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | 2023-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-04 | 2023-08-25 | 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 | 2023-08-04 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-04 | 2023-08-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-04 | 2023-08-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-08-04 | 2023-08-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-04 | 2023-08-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-04 | 2023-08-25 | 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 | 2023-08-04 | 2023-08-25 | 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 | 2023-08-04 | 2023-08-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-04 | 2023-08-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-04 | 2023-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-04 | 2023-08-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-04 | 2023-08-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-01 | 2023-08-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-01 | 2023-08-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-01 | 2023-08-25 | 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 | 2023-08-01 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-08-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-01 | 2023-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-01 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-01-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-03 | 2022-11-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-03 | 2022-11-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-03 | 2022-11-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-03 | 2022-11-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-15 | 2022-11-01 | 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 | 2022-06-15 | 2022-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-10-13 | 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 | 2022-06-15 | 2022-10-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-15 | 2022-10-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-15 | 2022-10-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-15 | 2022-10-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-15 | 2022-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-10-13 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-15 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-29 | 2022-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-29 | 2022-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-02 | 2022-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-06 | 2022-06-27 | 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 | 2022-02-24 | 2022-03-07 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish methods for sharing information. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-04-01 | 2021-06-01 | 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 | 2021-04-01 | 2021-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-01 | 2021-06-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-26 | 2021-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-26 | 2021-04-16 | 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 | 2021-03-26 | 2021-04-16 | 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 | 2021-03-26 | 2021-04-16 | 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 | 2021-03-26 | 2021-04-16 | N |
