Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fond Du Lac Lutheran Home during CMS and state inspections, most recent first.
A resident with ESRD, HIV, dementia, and DM2 was given Depakote ER for sexually inappropriate behavior before informed consent was obtained from the guardian/RP. The record lacked a signed consent form and showed no documentation that risks versus benefits were discussed before the first dose was administered; staff later noted the POA wanted to speak with dialysis before consenting, and the DON stated the dose was given before the RP was updated.
Food safety monitoring was not consistently documented in the kitchen. Surveyors found missing and incomplete logs for the dish machine, 3-compartment sink sanitizing solution, meal temperatures, and refrigerator/freezer temperatures, and also noted dish machine wash temperatures below the required minimum. The DM acknowledged the gaps and stated new staff were still learning to complete the logs.
Resident Not Included in Quarterly Care Conferences: A resident with intact cognition and responsibility for healthcare decisions was not included in quarterly care conferences as required. The resident reported not receiving notice of conference dates or times, while the DLCS acknowledged notifications were mailed to the wrong address and that later conferences included only facility staff. The DON stated quarterly conferences were expected and that the resident should have received notifications.
The facility failed to maintain its infection prevention and control program during care for two residents. An RN provided feeding tube care to a resident on EBP while wearing gloves but no gown, and used gloves were later found on a railing outside another resident’s room after CNAs completed a transfer and exited the room. The residents had significant medical conditions, including a feeding tube, severe cognitive impairment, and a cerebrospinal drainage device.
A resident with a history of hepatic encephalopathy and moderate cognitive impairment eloped from a facility due to inadequate supervision. Despite being assessed as high risk for elopement and having a WanderGuard, the resident managed to remove the device and leave the facility without staff knowledge. The facility failed to implement effective interventions and supervision, leading to a finding of Immediate Jeopardy.
A resident's bathroom was found with BM soiled cloths on the sink, indicating a failure to maintain a sanitary environment. The resident, who had no cognitive impairment, expressed concerns about cleanliness. A Medication Technician confirmed the improper handling of soiled linens, and the Director of Nursing acknowledged the lack of a specific policy for handling soiled items.
A CNA at the facility did not complete the required 12 hours of in-service training during their anniversary hire year, having only completed 7.25 hours. The training lacked coverage of the QAPI process. Despite communication efforts by the NHA, the CNA did not fulfill the training requirements.
The facility did not have written policies and procedures for a facility closure, potentially affecting all 56 residents. The NHA stated that the facility would follow state regulations but acknowledged the absence of a formal policy.
The facility did not implement its policies for preventing abuse, neglect, and theft by failing to conduct timely background checks for two CNAs. The BID forms for these CNAs were not dated, and there was no proof of completion within the required timeframe. The Assistant Nursing Home Administrator confirmed the issue, and no response was received from Human Resources for clarification.
A resident with a pacemaker was admitted to a facility without a care plan for pacemaker use, leading to a hospital admission after the pacemaker's battery expired. Despite the resident's history of heart issues, the facility did not schedule cardiologist appointments or monitor the pacemaker, resulting in a critical drop in heart rate. Staff interviews revealed a lack of protocol for managing residents with pacemakers, contributing to the oversight.
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. One resident, with intact cognition, reported verbal abuse by a CNA, but the investigation lacked immediate staff education. Another resident, with moderately impaired cognition, reported missing money, but the investigation was delayed and lacked follow-up on emotional needs. The facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. Observations and interviews revealed that CNA-to-resident ratios were not met, leading to long wait times for call light responses and incomplete care. Residents reported delays in receiving assistance, and staff expressed concerns about being unable to complete tasks due to insufficient staffing. The facility had stopped using agency CNAs, exacerbating the staffing shortages.
The facility compromised the dignity of three residents by serving meals on disposable dishware due to a kitchen staffing shortage. Meals were served in Styrofoam containers with plastic utensils, which residents found difficult to use. The Dietary Manager confirmed the use of Styrofoam was due to staffing issues and acknowledged it was not a home-like option. Residents expressed dissatisfaction, with one keeping silverware in their room to avoid using plasticware.
A facility failed to ensure a resident with a legal guardian had court-ordered protective placement, as required by law. The resident, with severe cognitive impairment and multiple diagnoses, lacked the necessary protective placement paperwork. The social worker was unaware of this requirement and had not secured the placement, although they contacted the Aging and Disability Resource Center for guidance.
A resident with diabetes and dementia was observed self-administering insulin without a documented assessment or physician's order. Despite having intact cognition, the facility failed to ensure the necessary protocols were followed, as confirmed by the DON.
A resident with intact cognition experienced verbal and mental abuse from another resident, who used offensive language and derogatory remarks. Despite staff awareness of the behavior, the facility did not consider it willful abuse, failing to protect the resident from emotional distress.
A facility failed to report an allegation of verbal abuse involving a resident, who was distressed by another resident's offensive language. Despite the facility's policy requiring immediate reporting of abuse allegations, the Nursing Home Administrator was not informed until two days later and decided not to report the incident to the State Agency, concluding it did not constitute willful abuse.
A resident at risk for pressure injuries due to dementia and immobility did not receive the required care as outlined in their care plan. Observations and staff interviews revealed that the resident was left in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff were unaware of the repositioning schedule, and the facility lacked a specific policy for repositioning.
A resident with a urinary catheter and neurogenic bladder experienced delays in receiving assistance with ADLs. The resident activated the call light, but a Nurse Extern turned it off without providing care, resulting in a 31-minute wait. The Director of Nursing acknowledged the issue, stating that call lights should remain on until care is delivered.
A resident with COPD had an unsecured oxygen cylinder stored upright in their room closet, contrary to the facility's policy requiring oxygen cylinders to be secured. This was observed by a surveyor and confirmed by staff, including an RN, the Facility Manager, and the DON, yet the issue persisted.
A resident with a history of colectomy and ileostomy did not receive appropriate care, leading to stool leakage due to overfilled bags and ill-fitting supplies. The facility lacked specific care orders and documentation, and staff were unfamiliar with the resident's needs.
A facility failed to assess and care plan the use of bed rails for a resident with severely impaired cognition. The resident, who had an activated POAHC, signed a consent form for bed rail use, which should have been signed by the POAHC. The facility lacked a policy for bed rail use, and the necessary assessment was not completed.
A Nurse Extern improperly disposed of an oxycodone tablet in the trash bin instead of following the facility's policy for controlled drug disposal, which requires the presence of two licensed healthcare professionals and proper documentation. The NE-O retrieved the medication and disposed of it in a drug disposal bottle without a second witness and failed to document the destruction in the narcotic log book.
The facility failed to properly label and date medications for several residents, leading to incorrect dosing and administration times. Observations showed that insulin vials and ophthalmic solutions were not dated when opened, and expired vaccines were found in the medication refrigerator. These actions violated the facility's medication storage policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies. A CNA did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. Another CNA did not don appropriate PPE while providing incontinence care to a resident on Enhanced Barrier Precautions (EBP). Additionally, the facility failed to implement EBP for two other residents, one with a gastrostomy tube and another with a stage 4 sacral decubitus pressure injury.
The facility failed to ensure proper treatment and care for a resident with diabetes mellitus by not obtaining detailed physician orders for insulin and blood sugar monitoring, not assessing the resident's ability to self-administer insulin, and not monitoring for signs of hypo/hyperglycemia. The facility also lacked a diabetic management policy.
The facility failed to investigate a fall and implement safety interventions for a resident with intellectual disabilities, bipolar disorder, dementia, and epilepsy. Despite a witnessed fall documented by a Hospice RN, the facility did not complete a follow-up investigation or implement safety precautions, leading to additional falls and injury.
A resident received IV fluids through an implanted port administered by an LPN who was not qualified to perform the procedure. The facility failed to ensure that an RN was present to supervise the LPN, as required by state regulations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to discuss the risks versus benefits of a psychotropic medication and obtain informed consent before administering Depakote ER to a resident with end stage renal disease, HIV, dementia, and type 2 diabetes mellitus. The resident had a guardian who served as the responsible party. An order for Depakote ER 250 mg daily was entered for sexually inappropriate behavior, and the medication was administered on the first day it was started. The record did not contain a signed informed consent form for the Depakote that was given, and there was nothing in the resident’s chart showing that the responsible party had been informed about the medication, its risks versus benefits, or consented before the dose was administered. A nurse note documented that the order was placed on hold because the power of attorney wanted to speak with dialysis before consenting to the medication. The DON later stated the medication had been reviewed by the pharmacist and provider, and that one dose was given before the responsible party was updated and informed consent was obtained. The DON also stated she expected nursing staff to obtain consent before entering a new order for a psychotropic medication.
Food Safety Monitoring and Documentation Deficiencies
Penalty
Summary
Food was not consistently stored, prepared, sanitized, or monitored in accordance with the facility’s stated food safety procedures and the Wisconsin Food Code. During surveyor review, the Dietary Manager confirmed the facility follows the Wisconsin Food Code and that staff should monitor dish machine temperatures and chlorine pH levels, test and document sanitizing solution temperatures and PPM in the 3-compartment sink, record cooked and holding temperatures for meals, and maintain refrigerator and freezer logs. The facility’s policies also required routine documentation of these temperatures and measurements during meal service and dishwashing activities. Surveyor review of the dishwasher logs for June and July 2025 found 38 missing dish machine temperatures and pH levels, and 39 wash temperatures below the required 120 degrees F. The Dietary Manager stated staff should run empty racks through the machine when temperatures are low, but the logs did not show corrective measures when temperatures were below the minimum. The Dietary Manager acknowledged the missing temperatures and pH levels and stated new staff were still learning to complete the logs. Surveyor also reviewed the 3-compartment sink logs for June through August 2025 and found the logs were not consistently completed, with multiple missing temperatures and PPM levels. Review of 155 meal temperature logs showed 32 meals without cooked temperatures, 30 meals without served holding temperatures, and 147 logs without a completion date. Refrigerator and freezer logs for the walk-in refrigerator, walk-in freezer, baker refrigerator, and baker freezer also contained numerous missing temperatures over the review period. The Dietary Manager acknowledged the missing documentation and stated new staff were still learning to complete the logs.
Resident Not Included in Quarterly Care Conferences
Penalty
Summary
The facility did not ensure that R8 was given the opportunity to participate in quarterly care conferences. R8 was admitted with diagnoses including surgical amputation of a toe, cellulitis of the left lower limb, sepsis, and diabetes. R8’s MDS assessment dated 8/29/25 showed a BIMS score of 15 out of 15, indicating intact cognition, and R8 was responsible for healthcare decisions. R8 told the surveyor that care plan conferences should occur quarterly but that R8 had not had a care plan conference since last year, did not recall receiving notification by mail at the facility, and said the DLCS did not tell R8 about conference dates or times. The facility’s policy stated that individual care plan reviews are to be held every three months and that the Life Coach will invite the individual or responsible party to the review. The DLCS stated that notifications had been sent by mail to R8’s home residence, acknowledged that this was an error, and said the notifications should have been mailed to R8 at the facility. The DLCS also stated that R8 was not verbally informed of scheduled care conferences or their outcomes, and verified that the last care conference R8 attended was on 11/5/24, with later conferences including only facility staff. The DON stated that care conferences should be scheduled quarterly and expected staff to provide notifications to R8, who did not have an activated POAHC.
Infection Control Lapses During Resident Care
Penalty
Summary
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 two residents observed during care. One resident had a feeding tube, was on Enhanced Barrier Precautions (EBP), and had diagnoses including schizoaffective disorder, anxiety, chronic respiratory failure, and difficulty swallowing. The resident’s record showed a history of gastrostomy feeding tube placement, moderate cognitive impairment, an activated POAHC, and a care plan noting reliance on tube feeding and EBP. During observed feeding tube care, the RN disconnected and flushed the tube while wearing gloves but not a gown, despite a sign and PPE cart outside the room indicating EBP. A second resident had diagnoses including seizure disorder, encephalopathy, and congenital hydrocephalus, with a cerebrospinal drainage device, severe cognitive impairment, and an activated POAHC. During an observed transfer and attempted incontinence check, two CNAs wore gloves, then removed them and exited the room after the resident refused care. Shortly afterward, used gloves were observed on the railing outside the resident’s room. The DON stated that leaving used gloves on a railing was not in accordance with the facility’s infection control practices.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as being at high risk for elopement. The resident, who had a history of hepatic encephalopathy, alcoholic cirrhosis of the liver, delirium, anxiety disorder, depression, and a history of falling, was ambulatory and used a walker and wheelchair for mobility. Despite being assessed as having moderate cognitive impairment, the resident was able to cut off a WanderGuard bracelet and elope from the facility without staff knowledge on multiple occasions. The resident's elopement risk was initially assessed as low, but after several incidents of wandering and increased confusion, the risk was reassessed as high. The facility placed a WanderGuard on the resident, but the resident managed to remove it multiple times. On one occasion, the resident left the facility and returned from a local store without staff knowledge. The facility's failure to implement effective interventions and supervision for the resident, despite the known risk and history of elopement attempts, led to the deficiency. Staff interviews and record reviews revealed that the facility did not have adequate measures in place to monitor the resident effectively. The resident's care plan included interventions such as structured activities and frequent checks, but these were not consistently implemented. The facility's lack of immediate and effective response to the resident's elopement risk and behavior resulted in a finding of Immediate Jeopardy.
Removal Plan
- Reviewed the facility's Elopement Prevention Policy and updated elopement protocol.
- Provided all staff education regarding supervision for residents at risk for elopement and steps to take if a resident cuts off a WanderGuard, requests a tool to cut off a WanderGuard, and/or continues to express a desire to leave the unit.
- Removed plaques at each stairwell doorway that contained a code to enter and exit the unit and placed a small label with the door code at the top of the door frame.
- Conducted a thorough sweep of all residents for elopement risk and exit-seeking behavior and ensured care plans were updated with interventions to address exit-seeking/unsafe behavior and/or statements to ensure safety.
- Initiated audits of residents with exit-seeking behavior for proper documentation, effectiveness of interventions, and elopement events. Audit results will be brought to the Quality Assurance Performance Improvement committee for review.
Deficiency in Maintaining a Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for a resident, identified as R5, who was observed with bowel movement (BM) soiled cloths on the bathroom sink. R5, who had no cognitive impairment and was responsible for their own healthcare decisions, expressed dissatisfaction with the cleanliness of the bathroom. The observation was made during a surveyor's visit, and the presence of the soiled cloths was confirmed by a Medication Technician (MT-C) who had assisted with R5's care earlier that day. MT-C acknowledged that soiled linens should not be placed on the sink and should be bagged and taken to the utility room. The Director of Nursing (DON-B) confirmed that the facility's usual practice is to place soiled linens directly in a bag for transport to the utility room, and verified that the soiled cloths should not have been left on the sink. However, the facility lacked a specific policy addressing the handling of soiled items, as the provided Standard Activities of Daily Living (ADL) Protocol did not include instructions on where staff should place soiled items during care. This oversight contributed to the deficiency observed in maintaining a clean and safe environment for the resident.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA-D, completed the required 12 hours of in-service training during their most recent anniversary hire year. CNA-D was hired on August 23, 2023, and by the time of the survey, had only completed 7.25 hours of the required training. This included 2.25 hours of electronic training and attendance at five staff meetings. The training completed did not cover all required topics, specifically missing the Quality Assurance and Performance Improvement (QAPI) process. The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged the deficiency, noting that CNA-D had not completed the online training by the due date and had overdue trainings. Despite efforts to communicate the training requirements through emails, CNA-D did not respond or complete the necessary training. The facility's failure to ensure CNA-D's compliance with training requirements was identified during a review of records and staff interviews conducted by the surveyor.
Lack of Facility Closure Policies
Penalty
Summary
The facility was found to lack policies and procedures for handling a facility closure, which could potentially impact all 56 residents. During an interview, the Nursing Home Administrator (NHA) indicated that the facility would adhere to state regulations in the event of a closure but admitted that there was no written policy in place to guide such an event.
Failure to Conduct Timely Background Checks for CNAs
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and theft by not ensuring thorough and timely background checks for two Certified Nursing Assistants (CNAs), identified as CNA-C and CNA-D. The facility's policy requires screening of employees, including verification of references, certification, and criminal background checks before they are allowed to work with residents. However, during a review, it was found that the Background Information Disclosure (BID) forms for CNA-C and CNA-D were not dated, and there was no proof that these forms were completed within the required timeframe. CNA-C, who was hired in 2004, did not have a BID form completed within the previous four years. Similarly, CNA-D, who was rehired in 2024, also lacked a dated BID form, and there was no evidence that the form was completed prior to or on the date of rehire. The Assistant Nursing Home Administrator confirmed the absence of dates on the BID forms and was unsure of the reason. Despite attempts to contact Human Resources for clarification, no response was received by the surveyor.
Failure to Monitor Pacemaker Leads to Hospitalization
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident with a pacemaker, leading to a significant health event. The resident, who had a history of acute congestive heart failure, symptomatic bradycardia, and sick sinus syndrome, was admitted to the facility with a pacemaker. Despite the resident's moderate cognitive impairment, they were responsible for their healthcare decisions. The facility did not have a care plan in place for the resident's pacemaker use, and there was no follow-up care or scheduled appointments with a cardiologist to monitor the pacemaker's functionality. This oversight resulted in the resident being admitted to the hospital after the pacemaker's battery expired, causing the resident's heart rate to drop to the 30s. Interviews with facility staff revealed a lack of awareness and protocol regarding the management of residents with pacemakers. The Assistant Director of Nursing and other staff members acknowledged that there was no process in place for residents admitted with pacemakers, and the resident's stable vital signs did not alert them to the need for monitoring. The Medical Doctor was aware of the pacemaker but did not ensure follow-up care, and there was confusion about who was responsible for checking the pacemaker. The resident and their family were also noted to have some responsibility, as the pacemaker transmitter from the resident's home was not brought to the facility upon admission.
Deficient Investigation of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. For the first resident, who had intact cognition and multiple medical conditions including type 2 diabetes and chronic kidney disease, an allegation of verbal abuse by a Certified Nursing Assistant (CNA) was reported. The investigation concluded without including staff education on abuse, neglect, and misappropriation. The Assistant Nursing Home Administrator (ANHA) was unaware that immediate education was necessary following a substantiated abuse allegation, which resulted in the employee's termination. The second resident, with moderately impaired cognition and conditions such as type 2 diabetes and anxiety, reported missing money from their dresser drawer. The investigation into this misappropriation was delayed, with the resident and like residents not interviewed until several days after the report. The investigation lacked documentation of follow-up with the resident regarding their emotional needs, and there was no evidence of staff education or interventions to safeguard the resident's belongings. The ANHA acknowledged the lack of follow-up and resolution, as the facility did not find evidence of theft and the money was not replaced. Overall, the facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents. The deficiencies in the investigation process and the failure to provide immediate education and emotional support to the residents highlight significant gaps in the facility's handling of abuse and misappropriation allegations.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the care needs of its residents, as evidenced by the review of staffing shifts and interviews with residents and staff. The facility's staffing plan, as outlined in the Facility Assessment, was not adhered to on 15 out of 30 shifts reviewed. Specifically, the Certified Nursing Assistant (CNA)-to-resident ratios were not met, leading to delayed response times to call lights and incomplete resident care. Observations and interviews revealed that call lights were not answered in a timely manner, and residents experienced delays in receiving necessary care. One resident, who had a urinary catheter and intact cognition, reported long wait times for call light responses, sometimes resorting to using a cell phone to contact staff. On one occasion, the resident waited 31 minutes for assistance after a nurse extern turned off the call light without providing the requested service. Another resident experienced a 37-minute wait for assistance after activating their call light. These delays in care were corroborated by multiple resident interviews, where concerns were raised about the timeliness and completeness of care, including issues with shower schedules and hygiene maintenance. Staff interviews further highlighted the staffing deficiencies, with CNAs expressing that they often felt rushed and unable to complete tasks adequately due to insufficient staffing levels. The facility had stopped using agency CNAs, which contributed to the staffing shortages. Staff reported being frequently asked to work extra hours and feeling pressured to rush through resident care. The Nursing Home Administrator acknowledged the staffing challenges and the facility's failure to meet the staffing ratios outlined in the Facility Assessment.
Dignity Compromised by Use of Disposable Dishware
Penalty
Summary
The facility failed to maintain the dignity of three residents by serving meals on disposable dishware, specifically Styrofoam containers and plastic utensils, due to a staffing shortage in the kitchen. On the morning of July 8, 2024, breakfast was served in Styrofoam containers, and during lunch, beverages were served in Styrofoam cups. Residents expressed dissatisfaction with the use of plastic utensils, which made it difficult to cut food, and one resident reported that their Cream of Wheat was served cold. Another resident mentioned keeping silverware in their room to avoid using plasticware, which they found difficult to handle due to mobility issues. The Dietary Manager confirmed that the use of Styrofoam was due to insufficient kitchen staff and acknowledged that it was not a home-like option for residents. The manager also stated that regular silverware should be provided unless a resident is on precautions, in which case disposable ware is used. However, the manager was unsure why some residents received plasticware when not on precautions. The use of Styrofoam cups for extra fluids was attributed to the lack of large enough cups, although the manager noted that the kitchen supplied plenty of plastic drink cups and coffee cups to the units.
Failure to Ensure Protective Placement for Resident with Legal Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal guardian had court-ordered protective placement in the least restrictive environment, as required by law. The resident, who was admitted with diagnoses including unspecified intellectual disability, senile degeneration of the brain, bipolar disorder, and dementia with behavioral disturbance, was severely cognitively impaired and had a guardian as a decision maker. Despite having Letters of Guardianship dated back to 1994, the facility did not have the necessary protective placement paperwork for the resident. The social worker at the facility was unaware of the requirement for protective placement and had not ensured it was obtained, although they had contacted the Aging and Disability Resource Center to inquire about it.
Lack of Assessment and Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R45, had a self-administration of medication assessment or a physician's order to self-administer medication. R45, who was admitted with diagnoses including diabetes mellitus and dementia, had a Minimum Data Set (MDS) assessment indicating intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, there was no documented assessment or physician's order authorizing R45 to self-administer insulin. During an observation, a Nurse Extern (NE) was seen drawing up insulin and handing it to R45, who then self-injected the insulin. The Director of Nursing (DON) confirmed that R45 did not have the necessary assessment or physician's order for self-administration of insulin, which was expected to be completed by the staff before allowing such practice.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident, R305, from verbal and mental abuse by another resident, R14. R305, who had intact cognition, reported feeling distressed and emotionally affected by R14's offensive language and behavior. R14, who also had intact cognition, was documented to have used derogatory language towards R305 and other residents, causing emotional distress. Despite being aware of R14's behavior, the Nursing Home Administrator did not consider the altercation between R14 and R305 as willful abuse. Multiple staff members, including registered nurses and a medication technician, confirmed R14's habit of using foul language and making negative comments about other residents within earshot. R14's behavior was documented in a behavior note, and staff interviews revealed that R14 often expressed agitation and made threats towards other residents. The facility's policy mandates immediate reporting of abuse, but the response to R14's behavior did not align with this policy, resulting in a failure to ensure an environment free from abuse for R305.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, R305, to the State Agency as required by their policy. The incident involved a conflict between R305 and another resident, R14, where R14 used offensive language towards R305, causing emotional distress. Despite the facility's policy mandating immediate reporting of abuse allegations, the Nursing Home Administrator (NHA) was not informed of the incident until two days later and concluded that the altercation did not constitute willful abuse, thus not reporting it to the State Agency. R305, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported feeling distressed by R14's behavior, which included derogatory remarks. R14, who also has intact cognition with a BIMS score of 13 out of 15, has a history of physical behavior directed towards others. The facility's failure to report the incident promptly and appropriately reflects a deficiency in adhering to their abuse reporting policy.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as R50, who was at risk for developing pressure injuries due to dementia and immobility. The care plan included interventions such as routine toileting, skincare for incontinence, repositioning every 2-3 hours, and the use of pressure-reducing devices. However, observations and staff interviews revealed that these interventions were not consistently followed. R50 was frequently observed in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff interviews indicated a lack of awareness and adherence to the care plan. A nurse extern and a CNA both acknowledged that R50 was not repositioned as often as required, with the CNA noting that R50 was sometimes left in the recliner all day. The Director of Nursing confirmed that staff should assist R50 with bathroom needs and repositioning every 2-3 hours, but this was not consistently practiced. The facility also lacked a specific policy for repositioning, contributing to the deficiency in care for R50.
Delayed Assistance with ADLs for Resident
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident, identified as R2, who had a urinary catheter and was diagnosed with neurogenic bladder. R2 had intact cognition, as indicated by a BIMS score of 15 out of 15. On two separate occasions, R2 experienced delays in receiving care after activating the call light. On the first occasion, R2 waited 31 minutes for assistance after the call light was turned off by a Nurse Extern (NE-O) who informed R2 that a Certified Nursing Assistant (CNA-N) would assist after returning from break. On the second occasion, NE-O again turned off the call light without providing care, resulting in a delay until CNA-N returned from break to change R2's brief. The surveyor's observations and interviews with R2, NE-O, and CNA-N confirmed the delay in care and the inappropriate practice of turning off the call light before care was provided. The Director of Nursing (DON-B) acknowledged the issue, stating that call lights should remain on until care is delivered and that a 31-minute response time is longer than expected. This deficiency highlights a lapse in the facility's protocol for responding to residents' needs in a timely manner, particularly for those requiring assistance with ADLs.
Unsecured Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards for one resident, identified as R14, who was part of a sample of 19 residents. R14, who has a diagnosis of chronic obstructive pulmonary disease (COPD), had an unsecured oxygen cylinder stored upright in their room closet. The facility's policy on the safe use of oxygen, dated 11/8/23, requires that oxygen cylinders be secured in an upright position. On 7/8/24, a surveyor observed the unsecured oxygen cylinder in R14's closet. Subsequent interviews with RN-D, the Facility Manager, and the Director of Nursing confirmed the oxygen cylinder was unsecured and should have been properly secured according to facility policy. Despite these acknowledgments, the surveyor observed the unsecured oxygen tank again on 7/10/24.
Inadequate Ileostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, identified as R12, who had a medical history of colectomy with end ileostomy. R12's care plan did not include ileostomy care, leading to issues such as stool leakage from the ileostomy dressing. The resident reported that the ileostomy collection bag was not emptied in a timely manner over a weekend, causing it to overfill and leak multiple times. Additionally, the facility used ill-fitting ostomy supplies, resulting in further leakage. Nursing notes documented instances of stool leakage and appliance changes due to these issues. The facility lacked specific orders for R12's ileostomy care, and the Treatment Administration Record did not document routine ileostomy care. Interviews with staff revealed a lack of familiarity with R12's ostomy care needs, and the facility did not have a policy on ostomy care. The Assistant Director of Nursing acknowledged that orders for ostomy care were not resumed after R12 returned from a hospitalization, and there was an expectation for staff to document ostomy care, which was not met.
Failure to Assess and Care Plan Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper assessment and care planning for the use of bed rails for a resident, identified as R38. R38 was observed with half rails on their bed, but there was no documented risk assessment for their use. Additionally, a risk versus benefits statement was signed by R38, despite R38 having an activated Power of Attorney for Healthcare (POAHC) due to severely impaired cognition, as indicated by a BIMS score of 5 out of 15. The facility lacked a policy for the use of bed rails, and the Director of Nursing confirmed that the side rail consent and release form should have been signed by R38's POAHC. Furthermore, although there was a side rail assessment available in the electronic medical record, it was not completed for R38.
Improper Disposal of Controlled Drug by Nurse Extern
Penalty
Summary
The facility failed to ensure the proper disposal of a controlled drug for one resident, identified as R22, during a medication administration review. A Nurse Extern (NE-O) was observed disposing of an oxycodone 5 mg tablet, a Schedule IV opioid medication, in the medication cart trash bin. When questioned by the surveyor, NE-O admitted to not knowing why the medication was discarded in such a manner and typically placed discarded medication in a bottle. NE-O retrieved the oxycodone tablet from the trash, along with a gabapentin 600 mg tablet and a methocarbamol 500 mg tablet, and subsequently disposed of them in a Destroyer Drug Disposal bottle without verifying the medication with a second witness. The facility's policy requires that medication destruction occurs in the presence of at least two licensed healthcare professionals, and the destruction must be documented in the narcotic log book. NE-O failed to adhere to these procedures, as there was no second witness present during the disposal, and the destruction of the oxycodone was not documented. This incident highlights a breach in the facility's medication disposal policy, which mandates specific steps to ensure controlled substances are disposed of safely and accurately.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and dated appropriately for six residents during medication administration. Observations revealed that staff administered open and undated medications to these residents, which included tamsulosin HCL, Admelog insulin, gabapentin, and ophthalmic solutions. In one instance, a nurse extern administered the wrong dose of tamsulosin HCL to a resident due to an incorrect label and administered a medication at the wrong time to another resident. Additionally, the insulin vials used for multiple residents were not dated when opened, contrary to the facility's policy. Further inspection of the second-floor medication refrigerator uncovered an open and undated multi-dose vial of octreotide acetate and four syringes of expired influenza vaccine. The facility's policy mandates that medications be labeled with an open date and that expired medications be removed and destroyed. However, these protocols were not followed, as evidenced by the presence of expired vaccines and undated vials in the medication storage area.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Certified Nursing Assistant (CNA)-M did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. CNA-M failed to perform hand hygiene between glove changes and did not change gloves between dirty and clean tasks during a bed bath and incontinence care. This was confirmed by the Director of Nursing (DON)-B, who acknowledged the lapse in protocol. Another deficiency was observed with CNA-N, who did not don appropriate personal protective equipment (PPE) while providing incontinence care to the same resident on Enhanced Barrier Precautions (EBP) due to a urinary catheter. Despite the presence of a PPE cart and signage indicating EBP, CNA-N only wore gloves and did not use a gown, contrary to facility policy. DON-B confirmed that staff should don full PPE for residents on EBP. Additionally, the facility failed to implement EBP for two other residents. One resident with a gastrostomy tube did not have appropriate signage or a PPE cart outside their room, and another resident with a stage 4 sacral decubitus pressure injury was not on the facility's EBP list. The DON confirmed these oversights, acknowledging that both residents should have been on EBP with proper signage and PPE availability.
Failure to Monitor and Manage Diabetes Care
Penalty
Summary
The facility did not ensure treatment and care in accordance with professional standards of practice for a resident with diabetes mellitus. The resident's medical record lacked detailed physician orders for insulin and blood sugar monitoring, and there was no assessment for the resident's ability to self-administer insulin or perform accuchecks. Additionally, the facility failed to monitor the resident's insulin use and blood sugar levels or check for signs and symptoms of hypoglycemia or hyperglycemia. The resident's care plan indicated that staff should monitor for these signs, but there was no documented proof of such monitoring in the medical record. The resident was admitted with an insulin pump and had a discharge summary that included an order for Humalog but no orders for blood sugar monitoring. The medical record did not contain insulin pump orders or orders for the frequency of blood sugar monitoring. The Director of Nursing confirmed that the facility did not assess the resident for diabetic management and that there were no documented records of the resident's insulin use or blood sugar results. The facility also lacked a diabetic management policy, which contributed to the oversight in monitoring and managing the resident's diabetes care.
Failure to Investigate and Prevent Falls
Penalty
Summary
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 one resident. On 3/19/24, a Hospice RN documented that the resident had a witnessed fall, but the facility did not complete a follow-up investigation or implement safety precautions to prevent further falls. The resident subsequently experienced additional falls on 3/23/24 and 3/27/24, with the latter resulting in a 1-inch reddened area on the forehead. The facility's Falls policy, reviewed on 6/24/22, mandates preventative measures to reduce falls and injuries, including completing a Fall Incident Report, updating care plans with identified interventions, and conducting follow-up assessments. However, the facility failed to adhere to this policy for the resident, who had a history of intellectual disabilities, bipolar disorder, dementia with behavioral disturbances, and epilepsy. The Assistant Director of Nursing acknowledged that the facility did not complete a fall investigation or implement safety interventions following the initial fall on 3/19/24.
LPN Administered IV Fluids Without Proper Qualifications
Penalty
Summary
The facility did not ensure that intravenous (IV) therapy treatment was administered by competent staff for one resident. On 11/18/23, an LPN administered IV fluids to a resident through the resident's implanted port, despite not being qualified to do so. The resident had been admitted with diagnoses including malignant neoplasm of the brain and protein-calorie malnutrition and had moderate cognitive impairment. The LPN administered the IV fluids without the direct supervision of an RN, as required by Wisconsin State Legislature Chapter N 6, which mandates that LPNs perform acts in complex patient situations under the direct supervision of an RN or provider. The Director of Nursing (DON) confirmed that the LPN was IV certified but not trained to access central lines, such as implanted ports. The facility's contracted pharmacy's Registered Nurse Educator (RNE) also verified that the certification courses did not cover central lines, as LPNs are not allowed to access them in Wisconsin. On the day of the incident, an RN was not present in the facility during the PM shift when the LPN administered the IV fluids. The DON acknowledged that an RN manager or the previous DON should have come in to administer the order, highlighting a lapse in ensuring proper supervision and competency in IV therapy administration for complex patient situations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fond Du Lac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Fond Du Lac | 0.3 mi | ★★★★★ | 6 | 0 |
| St Francis Home | 0.9 mi | ★★★★★ | 12 | 0 |
| Avina On Division | 1.2 mi | ★★★★★ | 11 | 1 |
| Harbor Haven Health & Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Edenbrook Of Fond Du Lac | 1.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.