Most Recent Deficiencies for Fond Du Lac Lutheran Home

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Updated as of August 01, 2022

A list of the most recent deficiencies for Fond Du Lac Lutheran Home. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-06-01 2022-07-01 Y
Respond appropriately to all alleged violations. Health 2022-06-01 2022-07-01 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-05-25 2022-06-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-25 2022-06-25 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-05-25 2022-06-25 N
Construct fire resistant interior walls. Fire Safety 2022-05-24 2022-06-25 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2022-05-24 2022-06-25 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-24 2022-06-25 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-05-24 2022-06-25 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 2022-05-24 2022-06-16 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-05-24 2022-06-15 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-05-24 2022-05-26 N
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Fire Safety 2022-05-24 2022-05-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-03-29 2022-04-22 Y
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 2022-03-29 2022-04-22 Y
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Health 2022-03-29 2022-04-22 Y
Employ staff that are licensed, certified, or registered in accordance with state laws. Health 2022-03-29 2022-04-22 Y
Provide and implement an infection prevention and control program. Health 2022-03-29 2022-04-22 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-02-10 2022-03-10 Y
Respond appropriately to all alleged violations. Health 2022-02-10 2022-03-10 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-02-10 2022-03-10 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-05-12 2021-09-01 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-05-12 2021-06-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-05-12 2021-06-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-05-12 2021-06-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-05-12 2021-06-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-05-12 2021-06-12 N
Provide enough food/fluids to maintain a resident's health. Health 2021-05-12 2021-06-12 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-05-12 2021-06-12 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-05-12 2021-06-12 N
Provide and implement an infection prevention and control program. Health 2021-05-12 2021-06-12 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2021-05-12 2021-06-12 N
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Health 2021-05-12 2021-06-12 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-05-12 2021-06-12 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-05-12 2021-06-12 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-05-12 2021-06-12 Y
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 2021-05-12 2021-06-12 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-05-12 2021-06-12 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 2021-05-12 2021-06-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-05-12 2021-06-12 N
Install an approved automatic sprinkler system. Fire Safety 2021-05-12 2021-06-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-05-12 2021-06-12 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-05-12 2021-06-12 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-05-12 2021-06-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-09-29 2020-10-29 Y
Provide and implement an infection prevention and control program. Health 2020-09-29 2020-10-29 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2020-02-05 2020-03-05 Y
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 2020-02-05 2020-03-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-02-05 2020-03-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2020-02-05 2020-03-05 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2020-02-05 2020-03-05 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2020-02-05 2020-03-05 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2020-02-05 2020-03-05 Y
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 2020-02-05 2020-03-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-10-17 2019-11-05 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 2019-10-10 2019-11-05 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-10-10 2019-11-05 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 2019-08-20 2019-11-05 Y
Respond appropriately to all alleged violations. Health 2019-08-20 2019-09-19 Y
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 2019-08-20 2019-09-19 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-08-20 2019-09-19 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2019-08-20 2019-09-19 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-06-25 2019-07-25 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-06-25 2019-07-25 N
Ensure each resident receives an accurate assessment. Health 2019-06-25 2019-07-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-06-25 2019-07-25 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-06-25 2019-07-25 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 2019-06-25 2019-07-25 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 2019-06-25 2019-07-25 N
Provide and implement an infection prevention and control program. Health 2019-06-25 2019-07-25 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-06-25 2019-07-25 N
Provide properly protected cooking facilities. Fire Safety 2019-06-25 2019-07-25 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-06-25 2019-07-25 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-06-25 2019-07-25 N