Fond du Lac Lutheran Home

In the surveyor’s words

From the most serious findings on record at Fond du Lac Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 27, 2025

  Based 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. […]

• Actual harm, isolatedF684Sep 24, 2024

  Based 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.) Findings include: On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and readmitted on [DATE] following hospitalization for pacemaker failure. […]

• No harm, potential for more than minimal, widespreadF812Sep 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725May 24, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF725Jul 10, 2024

  Based 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. […]