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Deficiency Records for Fond Du Lac Lutheran Home
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.
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 an enclosure around a vertical opening shaft. | Fire Safety | 2024-07-11 | 2024-09-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-07-11 | 2024-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-11 | 2024-09-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-11 | 2024-09-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-11 | 2024-09-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-07-11 | 2024-08-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-11 | 2024-08-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-10 | 2024-08-06 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-07-10 | 2024-08-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-10 | 2024-08-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-10 | 2024-08-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-10 | 2024-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-10 | 2024-08-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-10 | 2024-08-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-10 | 2024-08-06 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-07-10 | 2024-08-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-07-10 | 2024-08-06 | 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 | 2024-07-10 | 2024-08-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-10 | 2024-08-06 | 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 | 2024-07-10 | 2024-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-10 | 2024-08-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Develop a communication plan. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2024-07-11 | 2024-08-05 | 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 | 2024-07-11 | 2024-08-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-07-11 | 2024-08-05 | 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 | 2024-07-11 | 2024-08-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-10 | 2024-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-10 | 2024-05-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-10 | 2024-05-09 | 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 | 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 |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-11 | Not Fixed | N |
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