Fondulac Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Fondulac Rehabilitation and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 11, 2023

  Based on interview and record review, the facility failed to supervise a cognitively impaired resident during an evening dinner meal and follow a Physician's Diet Order for a Mechanically Altered Diet for one resident (R2). These failures results in R2 choking, requiring Cardiopulmonary Resuscitation and subsequently died . These failures have the potential to affect all twelve residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) residing in the facility that receive a Mechanically Altered Diet for residents reviewed for diets received in a sample of 14. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. […]

• Immediate jeopardy, patternF689Nov 3, 2022

  Based on observation, interview and record review, the facility failed to assess, monitor, and supervise a cognitively impaired, oxygen dependent resident (R5) during a designated smoking time for three residents reviewed for smoking in a sample of five. This failure resulted in R5 suffering [CONDITION(S)] to the face and requiring hospitalization causing R5 to become intubated and admitted to the burn unit. These failures have the potential to affect all eleven smoking residents residing in the Facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11/2/22, the facility remains out of compliance at a severity level two. […]

• Immediate jeopardy, isolatedF628May 20, 2026

  Based on interview and record review the facility failed to follow their own discharge policy for discharging a resident for one resident (R5). This failure led to R5 being discharged to a home with no running water, with all of R5's medical supplies being left in the weather elements and being ruined, no food in the home and no home health assistance as ordered by the doctor. The failure of leaving R5's medical supplies on the porch has the potential for R5 to get infections in wounds that could lead to hospitalizations, serious illness or even death. The failure to have no home health set up for home could lead to multiple health concerns worsening and causing illness, hospitalizations and death. […]

• Immediate jeopardy, isolatedF600May 28, 2025

  Based on observation, interview, and record review the facility failed to protect a resident (R2) from resident-to-resident sexual abuse for one of four residents (R2) reviewed for abuse in the sample of ten. This failure resulted in R1 a cognitively intact resident sexually assaulting R2 a cognitively impaired resident on more than one occasion. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse. […]

• Immediate jeopardy, isolatedF689May 28, 2025

  Based on observation, interview, and record review the facility failed to initiate a resident head count once an exit door was alarming without known cause, failed to ensure a gait to the outside smoking patio was kept secure, failed to develop a care plan and implement interventions for residents at risk for elopement, and failed to provide adequate supervision for two of three residents (R6 and R7) reviewed for elopement risk in the sample of 10. These failures resulted in cognitively impaired resident (R6) who required assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge or supervision on 4-22-25, and being found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. […]