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Fond Du Lac Lutheran Home

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About Fond Du Lac Lutheran Home

General Information

Legal Business NameFond Du Lac Lutheran Home, Inc.
Ownership TypeNon Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 1, 2000 (17 years)
Capacity94
Residents83
Percent Occupied88%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityYes
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Fond Du Lac Lutheran Home

Fond Du Lac Lutheran Home
was reviewed by Medicare to have a rating of 4 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Wisconsin Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 2, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintMake sure that doctors visit residents regularly, as required.
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

February 16, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
ESomePotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

February 11, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
ESomePotential for HarmFire Safety InspectionCorridors that are separated from use areas by walls constructed to limit the passage of smoke.
DFewPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.

March 11, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
CManyPotential for Minimal HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
DFewPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
DFewPotential for HarmFire Safety InspectionApproved construction type or materials.

February 25, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Fond Du Lac Lutheran Home require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 50min
2hr 40min
ReportedExpected
CNA
35min
40min
ReportedExpected
LPN
1hr 5min
1hr
ReportedExpected
RN
4hr 35min
4hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.6%
93.4%
93.4%
97.6%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Seasonal Influenza Vaccine
92.8%
95.4%
100.0%
97.9%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Pneumococcal Vaccine
71.0%
-
-
45.1%
Q1 2015Q2 2015Q3 2015WI
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
15.9%
15.0%
13.8%
13.3%
Q1 2015Q2 2015Q3 2015WI
Received an Antipsychotic Medication
7.0%
11.5%
14.3%
14.3%
Q1 2015Q2 2015Q3 2015WI
Need for Help with ADLs has Increased
7.7%
7.4%
12.7%
9.3%
Q1 2015Q2 2015Q3 2015WI
Self Report Moderate to Severe Pain
9.0%
4.6%
8.1%
7.5%
Q1 2015Q2 2015Q3 2015WI
Lose Too Much Weight
1.8%
5.4%
1.8%
4.3%
Q1 2015Q2 2015Q3 2015WI
High Risk Residents With Pressure Ulcers
4.5%
4.6%
0.0%
5.6%
Q1 2015Q2 2015Q3 2015WI
Have Depressive Symptoms
0.0%
1.5%
1.6%
4.5%
Q1 2015Q2 2015Q3 2015WI
With a Urinary Tract Infection
0.0%
1.5%
1.6%
3.1%
Q1 2015Q2 2015Q3 2015WI
Experiencing One or More Falls with Major Injury
5.5%
1.6%
3.3%
3.9%
Q1 2015Q2 2015Q3 2015WI
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.4%
Q1 2015Q2 2015Q3 2015WI
Were Physically Restrained

Quality Measures for Short Stay Residents

95.6%
96.7%
86.8%
89.6%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Pneumococcal Vaccine
94.4%
94.4%
94.4%
88.4%
Q1 2015Q2 2015Q3 2015WI
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
28.8%
34.7%
36.2%
20.3%
Q1 2015Q2 2015Q3 2015WI
Self Report Moderate to Severe Pain
1.6%
1.5%
3.3%
1.2%
Q1 2015Q2 2015Q3 2015WI
Newly Received an Antipsychotic Medication
2.4%
0.0%
2.4%
1.0%
Q1 2015Q2 2015Q3 2015WI
With Pressure Ulcers That Are New or Worsened