Deficiency Records for Crossroads Care Center of Fond Du Lac
Updated as of March 01, 2024
A list of the most recent deficiencies for Crossroads Care Center 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-11-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-19 | 2023-11-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-19 | 2023-11-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-16 | 2023-06-16 | 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 | 2023-05-16 | 2023-06-16 | 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 | 2023-05-16 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-16 | 2023-06-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-16 | 2023-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-21 | 2023-04-17 | 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 | 2023-03-15 | 2023-04-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-18 | 2022-07-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-18 | 2022-07-01 | 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 | 2022-05-18 | 2022-07-01 | N |
| Provide appropriate foot care. | Health | 2022-05-18 | 2022-07-01 | 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 | 2022-05-18 | 2022-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-06-01 | 2022-06-28 | Y |
| 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 | 2022-06-01 | 2022-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-04 | 2022-06-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-02 | 2022-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-11-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-16 | 2021-09-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-28 | 2021-05-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-28 | 2021-05-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-28 | 2021-05-26 | 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 | 2021-04-28 | 2021-05-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-05-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-28 | 2021-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-26 | 2021-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-26 | 2021-05-26 | N |
