Fond Du Lac Lutheran Home

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to discuss risks versus benefits and obtain informed consent for the use of psychotropic medication for 1 resident (R) (R4) of 3 sampled residents. The deficient practice had the potential to cause a psychosocial decline in R4's mental status.

Inspectors wroteBased on staff interview and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 50 of 51 residents residing in the facility. (One resident received nutritional needs via tube feeding.)Staff did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles temperatures or chemical pH levels for the chlorine sanitizer. Staff did not consistently test and document the parts per million (PPM) and temperature of the sanitizing solution in the 3-compartment sink. Staff did not consistently monitor and document cooked food temperatures or hot/cold holding temperatures. Staff did not consistently maintain kitchen cooler and freezer logs.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the opportunity to participate in quarterly care conferences was provided for 1 resident (R) (R8) of 22 sampled residents. The facility did not include R8 in quarterly care conferences since 11/5/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R6 and R7) of 3 residents observed during the provision of cares. R6 had a feeding tube and was on enhanced barrier precautions (EBP). During an observation of care for R6, Registered Nurse (RN)-D did not wear the appropriate personal protective equipment (PPE). Used gloves were observed on a railing outside R7's room following an observation of care for R7.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 resident received adequate supervision to prevent elopement. On 2/23/25, R1 was assessed to be at risk for elopement after R1 attempted to elope fromv the facility. Staff placed a WanderGuard bracelet on R1. On 2/24/25, R1 expressed a desire to leave the facility and go to a local store. On 2/26/25, R1 cut off R1's WanderGuard and a new WanderGuard was applied. On 2/28/25 at 8:35 AM, R1 left the facility without staffs' knowledge and was redirected back into the facility. On 2/28/25 at 3:30 PM, staff found R1 outside walking back from a local store that was approximately 0.3 miles from the facility. R1 had eloped from the facility without staffs' knowledge. [...]

Inspectors wroteBased on observation and staff and resident interview, the facility did not provide a safe, sanitary, or home-like environment for 1 resident (R) (R5) of six sampled residents. On 3/25/25, bowel movement (BM) soiled cloths were observed on R5's bathroom sink.

Inspectors wroteBased on staff interview and record review, the facility did not ensure required nurse aid training was completed for 1 of 5 sampled Certified Nursing Assistants (CNAs). CNA-D was hired on 8/23/23. CNA-D did not have 12 hours of in-service training during CNA-D's most recent anniversary hire year.

Inspectors wroteBased on staff interview, the facility did not have policies and procedures in place to use in the case of a facility closure. This had the potential to affect all 56 residents residing in the facility. The facility did not have policies and procedures to address a facility closure.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely background check was completed for Certified Nursing Assistant (CNA)-D.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure care and treatment were provided for 1 resident (R) (R1) of 3 sampled residents with a pacemaker (a device placed in the body to support the electrical system in the heart). Staff did not assist R1 in scheduling appointments with a cardiologist to check R1's cardiac health or ensure R1's pacemaker worked properly. On [DATE], R1 was admitted to the hospital after R1's pacemaker battery died and R1's heart rate was in the 30s. (A typical resting heart rate for adults is between 60 and 100 beats per minute.)

Inspectors wroteBased on staff and resident interview and record review, the facility did not thoroughly investigate allegations of abuse and misappropriation for 2 residents (R) (R2 and R3) of 2 sampled residents. The facility did not thoroughly investigate an allegation of abuse for R2. The facility did not thoroughly investigate an allegation of misappropriation for R3.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure sufficient staffing to meet residents' care needs. This had the potential to affect multiple residents residing in the facility. Fifteen of 30 staffing shifts reviewed did not meet Certified Nursing Assistant (CNA)-to-resident staffing ratios outlined in the the Facility Assessment which was last updated in April of 2024. Observations indicated call lights were not answered timely and resident care was not provided timely. Resident and staff interviews identified concerns with the provision and receipt of timely and complete care.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure dignity was maintained for 3 residents (R) (R305, R45, and R12) of 19 sampled residents who were served meals on disposable dishware. On 7/8/24, breakfast was served in Styrofoam containers because the kitchen was short staffed. During lunch service, staff were observed serving milk and coffee in Styrofoam cups. In addition, resident interviews indicated residents were provided with disposable utensils which made it difficult to cut food.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R43) of 2 residents reviewed for guardianship. R43 had a legal guardian. The facility did not ensure R43 had court-ordered protective placement in the least restrictive environment at the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R45) of 1 sampled resident had a self-administration of medication assessment or a physician's order to self-administer medication. R45 did not have a self-administration of medication assessment that indicated R45 could safely and accurately self-administer medication. In addition, R45 did not have a physician's order to self-administer medication.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure an environment that was free from abuse for 1 resident (R) (R305) of 1 sampled resident. The facility did not protect R305's right to be free from verbal and mental abuse by R14.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R305) of 1 sampled resident. The facility did not report an allegation of verbal abuse to the SA for R305.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the comprehensive care plan was implemented for 1 resident (R) (R50) of 19 sampled residents. R50's comprehensive care plan indicated R50 was at risk for developing pressure injuries. The facility did not implement R50's care plan intervention to ensure the prevention of skin breakdown.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure assistance with activities of daily living (ADLs) was provided care in a timely and consistent manner for 1 resident (R) (R2) of 19 sampled residents. R2 waited 31 minutes for staff to provide care. In addition, staff turned R2's call light off prior to providing care.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R14) of sampled 19 residents. An unsecured oxygen cylinder was stored in R14's room.

Inspectors wroteResident #12 Bladder and Bowel Incontinence 07/08/24 01:07 PM Reports Friday & sunday: ostomy was not emptied in timely fashion. Ostomy bag overfilled & Leaked. Resident reports sitting in stool for several hours. Resident claims this has happened numerous times. Facility runs out of the appropriate ostomy bags, when wrong size is used she has issues with leakage. 07/10/24 09:36 AM Type: Nurse's Note Focus: Effective Date: 6/10/2024 01:04:00 Department: *Nursing Position: *Registered Nurse Created By: [NAME] Created Date : 6/10/2024 01:05:45 Record review: 6/10/2024 01:04 Nurse's Note Note Text: colostomy wafer & bag changed d/t blowout. Tolerated procedure well 07/10/24 11:19 AM Record review: No tasks for ostomy care. No regular documentation of ostomy care. No orders for ostomy dressing or care. 07/10/24 12:07 PM Interview with [NAME]: [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R12) of 1 sampled resident received appropriate ileostomy care. R12's ileostomy care was not care planned which resulted in stool leakage from R12's ileostomy dressing.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure use of bed rails was assessed and care planned for 1 resident (R) (R38) of 1 sampled resident. R38 had half rails on R38's bed. R38 did not have a risk assessment for the use of half rails. In addition, a risk versus benefits statement was signed by R38, however, R38 had an activated Power of Attorney for Healthcare (POAHC).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a controlled drug was disposed of appropriately for 1 resident (R) (R22) of 15 sampled residents reviewed for medication administration. Nurse Extern (NE)-O disposed of oxycodone (a schedule IV opioid medication used to treat severe pain) in the medication cart trash bin. In addition, NE-O did not document the destruction of the oxycodone and did not have a second witness present.

Inspectors wroteBased on observation, staff interview, and record review the facility did not ensure medications were labeled and dated appropriately for 6 residents (R) (R38, R1, R32, R45, R19, and R9) of 15 sampled residents observed during medication administration. In addition, the facility also did not ensure medications in the second floor mediation refrigerator were dated when opened and disposed of when expired. During multiple observations of medication administration, Surveyor observed staff administer open and undated medications to R38, R1, R32, R45, R19, and R9. During an observation of medication administration, Nurse Extern (NE)-O administered the wrong dose of medication to R38 due to an incorrect label. In addition, NE-O administered a medication to R45 at the wrong time due to an incorrect label. [...]

Inspectors wroteFACILITY Infection Control Sample one staff to verify compliance with requirements for educating and offering COVID-19 immunization (select one staff from the actual working schedules for all staff provided during entrance conference). 1. [NAME] CNA : INTV 0906- Educated on COVID w pamphlets. Received COVID vax x2. no boosters. Received info on IC in Relias like Donning & Doffing PPE & res who might be at risk Reviewed COVID Vax Pfizer 9/26/22 & 12/12/22 INTV DON 1244: in AM mtg will go over which res is on what precaution & when they come of it.no list of what res are on what precautions currently but will put together a list Sample three residents on transmission-based precautions (TBP) for purposes of determining compliance with infection prevention and control national standards, as well as resident care, screening, testing, and reporting. 1. [NAME] Per DON Not on Contact 2. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure treatment and care in accordance with professional standards of practice for 1 resident (R) (R2) of 21 sampled residents. The facility did not obtain detailed physician orders for R2's insulin and blood sugar monitoring. The facility also did not assess R2 for self-administration of insulin or accuchecks. In addition, the facility did not monitor R2's insulin use and blood sugar levels or monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Inspectors wroteBased on staff interview and record review, the facility did not ensure a fall was thoroughly investigated to determine root cause, implement appropriate interventions to prevent reoccurrence, or ensure the environment was as free from accident hazards as possible for 1 resident (R) (R7) of 3 sampled residents. On 3/19/24, a Hospice Registered Nurse (RN) documented that R7 had a witnessed fall. The facility did not complete a follow up investigation and did not implement safety precautions to prevent further reoccurrence. R7 had additional falls on 3/23/24 and 3/27/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure intravenous (IV) therapy treatment was administered by competent staff for 1 resident (R) (R1) of 1 sampled resident. On 11/18/23, Licensed Practical Nurse (LPN)-D administered IV fluids to R1 through R1's implanted port; however, LPN-D was not qualified to administer IV fluids through an implanted port.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. This had the potential to affect multiple residents residing in the facility. In addition, staff did not perform proper hand hygiene during the provision of care for 3 Residents (R) (R1, R5 and R4) of 8 sampled residents. [...]

Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 1 Resident (R) (R6) of 8 sampled residents. On 10/3/23, R6's significant other filed a grievance regarding call light response times and incontinence care. R6 denied R6 received follow up and resolution of the grievance. On 10/20/23, R6 filed a grievance regarding care received by Certified Nursing Assistant (CNA)-I. R6 denied R6 received follow up and resolution of the grievance.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment were provided in accordance with professional standards of practice for 1 Resident (R) (R2) of 12 sampled residents. R2 vomited on 11/10/23 and 11/11/23. The facility did not administer physician ordered anti-nausea medication.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure sufficient staffing to meet residents' care needs. This had the potential to affect all 59 residents residing in the facility. Thirteen of seventeen staffing shifts reviewed did not meet the Certified Nursing Assistant (CNA) to resident staffing ratios outlined in the Facility Assessment which was updated in April 2023. Residents and staff interviewed expressed concerns with receiving and providing timely and complete care. Observations indicated call lights weren't answered timely, resident care was not provided timely and a resident who returned from the hospital was not attended to in a timely manner.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R12 and R29) of 21 residents were assessed as able to safely and accurately self-administer medication. R12 did not have a current self-administration of medication assessment for medications to be left at the bedside. R29 did not have a self-administration of medication assessment or a physician order to self administer medication.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure prompt resolution of a grievance for 1 Resident (R) (R47) of 21 residents. In addition, the grievance was not contained in the facility's grievance file. The facility did not document, investigate, and follow up with R47 or R47's Power of Attorney (POA) when the facility was notified of R47's missing hearing aid.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure an allegation of abuse for 1 Resident (R) (R6) of 21 sampled residents was reported to the State Agency (SA) in a timely manner. R6 reported an allegation of abuse to staff on 5/19/23. The allegation of abuse was not reported to the SA in a timely manner.

Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R6) of 21 sampled residents. On 5/19/23, R6 reported an allegation of abuse. The allegation of abuse was not thoroughly investigated.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R2, R153, and R154) of 21 residents who required assistance of staff for activities of daily living (ADLs) were provided care in a timely and consistent manner. R2 was admitted to the facility on [DATE] and had one documented shower and three skin evaluations since admission. R153 was admitted to the facility on [DATE] and had one documented shower since admission. R154 was admitted to the facility on [DATE] and had no documented showers since admission.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical and mental well-being for 1 Residents (R) (R102) of 21 sampled residents. R102's Admit/Readmit Screener, dated 5/19/23, did not contain documentation of a cyst R102 had surgically drained in the hospital prior to admission. R102 was not provided care for the cyst for three days after admission.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 Residents (R) (R102 and R22) of 3 residents reviewed for pressure injuries received the necessary care and services to promote healing. R102 was admitted to the facility on [DATE] with a stage 2 pressure injury. A treatment order was not obtained until 5/22/23 when Wound Nurse Practitioner (NP)-Q assessed R102 and determined the pressure injury was unstageable. R22's medical record indicated R22 had a stage 3 pressure injury on the buttocks. During an observation of care, Assistant Director of Nursing (ADON)-C stated R22 had a foam dressing over the pressure injury which was not in accordance with R22's treatment order.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 2 Residents (R) (R102 and R29) of 21 sampled residents. R102 and R29 stored cigarettes and lighters in their rooms which was not in accordance with the facility's protocol.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R19 and R16) of 5 residents reviewed for immunizations were offered a pneumococcal vaccine. R19's medical record did not contain documentation that R19 was offered a 2nd pneumococcal vaccine. R16's medical record did not contain documentation that R16 was offered a pneumococcal vaccine.