Deficiency Records for Fond Du Lac Lutheran Home
Updated as of August 01, 2021
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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-12 | 2021-09-01 | 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 | 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 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 |
| 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 |
| 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 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 |
| 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 necessary and PRN use is limited. | 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 an enclosure around a vertical opening shaft. | 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 |
