Deficiency Records for Fond Du Lac Lutheran Home
Updated as of August 01, 2019
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? |
|---|---|---|---|---|
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2018-08-07 | 2018-09-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-07 | 2018-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-07 | 2018-09-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-08-09 | 2018-09-09 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-08-09 | 2018-09-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-09 | 2018-09-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-08-09 | 2018-09-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-09 | 2018-09-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-09 | 2018-09-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-09 | 2018-09-09 | N |
| 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 | 2018-08-09 | 2018-09-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-09 | 2018-09-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-08-09 | 2018-09-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-08-09 | 2018-09-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-09 | 2018-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-09 | 2018-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-09 | 2018-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-09 | 2018-09-09 | 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 ne | Health | 2018-08-09 | 2018-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-09 | 2018-09-09 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-08-07 | 2018-08-20 | 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 | 2018-08-07 | 2018-08-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-12 | 2018-05-12 | Y |
| 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 |
| 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 |
