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? |
---|---|---|---|---|
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 | 2023-11-27 | 2023-12-27 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-27 | 2023-12-27 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-11-27 | 2023-12-27 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-17 | 2023-09-08 | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-17 | 2023-09-08 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-09-01 | Y |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-24 | 2023-07-07 | N |
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 | 2023-05-24 | 2023-07-07 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-24 | 2023-07-07 | N |
Respond appropriately to all alleged violations. | Health | 2023-05-24 | 2023-07-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-24 | 2023-07-07 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-24 | 2023-07-07 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-07 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-24 | 2023-07-07 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-24 | 2023-07-07 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-24 | 2023-07-07 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Meet other general requirements that are deficient. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-17 | 2023-04-14 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-02 | 2023-03-02 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-02 | 2023-03-02 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-03-02 | Y |
Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-03-02 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-14 | 2022-12-14 | Y |
Respond appropriately to all alleged violations. | Health | 2022-11-14 | 2022-12-14 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-07 | 2022-10-05 | Y |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-09-07 | 2022-10-05 | Y |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-07-31 | 2022-08-24 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-31 | 2022-08-24 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-31 | 2022-08-24 | 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 | 2022-07-31 | 2022-08-24 | Y |
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 |