Deficiency Records for Fond Du Lac Lutheran Home
Updated as of April 01, 2018
This is not the most recent data for Fond Du Lac Lutheran Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2017-06-20 | 2017-07-22 | 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 | 2017-06-20 | 2017-07-22 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2017-06-20 | 2017-07-22 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-06-22 | 2017-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-22 | 2017-07-22 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-06-22 | 2017-07-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-22 | 2017-07-22 | N |
| Ensure that all full-time nurse aides employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. | Health | 2017-06-22 | 2017-07-22 | N |
| Use approved construction type or materials. | Fire Safety | 2017-06-20 | 2017-07-18 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2017-06-20 | 2017-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-20 | 2017-07-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-20 | 2017-06-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-06-20 | 2017-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-20 | 2017-06-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-06-20 | 2017-06-20 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-16 | 2017-06-16 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-16 | 2017-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-06-15 | 2016-07-08 | Y |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2016-04-21 | 2016-05-20 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-04-21 | 2016-05-20 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-04-21 | 2016-05-20 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-04-20 | 2016-05-20 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-04-20 | 2016-05-20 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-04-20 | 2016-05-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-04-20 | 2016-05-20 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-04-20 | 2016-05-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-04-20 | 2016-05-20 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-09-02 | 2015-10-02 | Y |
| Make sure that doctors visit residents regularly, as required. | Health | 2015-09-02 | 2015-10-02 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2015-02-16 | 2015-03-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-02-16 | 2015-03-12 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-02-16 | 2015-03-12 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-02-16 | 2015-03-12 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-02-16 | 2015-03-12 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-02-16 | 2015-03-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-02-16 | 2015-03-12 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2015-02-16 | 2015-03-12 | N |
| Properly protected cooking facilities. | Fire Safety | 2015-02-11 | 2015-03-11 | N |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2015-02-11 | 2015-02-12 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2015-02-11 | 2015-02-12 | N |
