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? |
|---|---|---|---|---|
| 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-21 | 2021-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-10 | 2021-06-10 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-04-08 | 2021-05-07 | Y |
| 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 | 2021-04-08 | 2021-05-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-08 | 2021-05-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-08 | 2021-05-07 | Y |
| 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 | 2021-03-08 | 2021-05-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-08 | 2021-05-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-08 | 2021-05-07 | Y |
| 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 | 2021-02-10 | 2021-05-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-02-10 | 2021-05-07 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-03-08 | 2021-04-15 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-02-09 | 2021-03-31 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-02-10 | 2021-03-26 | N |
| 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 | 2021-02-10 | 2021-03-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-02-10 | 2021-03-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-10 | 2021-03-26 | 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 | 2021-02-10 | 2021-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-10 | 2021-03-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-09 | 2021-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-09 | 2021-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-02-09 | 2021-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-09 | 2021-03-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-09 | 2021-03-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-02-09 | 2021-03-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-02-09 | 2021-03-05 | N |
