Deficiency Records for Fond Du Lac Lutheran Home
Updated as of April 01, 2020
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? |
|---|---|---|---|---|
| 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 schedul | 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 |
| 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 |
| 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 ne | 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-17 | 2018-12-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-17 | 2018-12-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-17 | 2018-12-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-08 | 2018-12-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-08 | 2018-12-17 | 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 | 2018-10-24 | 2018-12-10 | 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 | 2018-10-24 | 2018-12-10 | Y |
| Post nurse staffing information every day. | Health | 2018-10-24 | 2018-12-10 | 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 | 2018-10-08 | 2018-12-10 | 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 | 2018-10-08 | 2018-12-10 | Y |
| 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 | 2018-10-08 | 2018-11-09 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-10-08 | 2018-11-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-10-08 | 2018-11-09 | Y |
| 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-21 | 2018-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-02-21 | 2018-03-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-21 | 2018-03-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-27 | 2018-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2017-12-27 | 2018-03-26 | 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 | 2017-12-27 | 2018-02-22 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2017-12-27 | 2018-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-27 | 2018-01-25 | 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 | 2017-12-27 | 2018-01-25 | 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 |
