Cycle 1
Health 2024-07-10 · Fire 2024-07-10
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
27 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Fond Du Lac, WI
Fond Du Lac Lutheran Home
1-star overall rating with 2-star inspections with $9,113 in total fines with 19 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
244 N Macy St, Fond Du Lac, WI
(920) 921-9520
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,721
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.90
Baseline 18.24% · Performance 19.16% · Measure score 4.90 · Achievement 4.90 · Improvement 0
Healthcare-associated infections
2.77
Baseline 5.85% · Performance 7.01% · Measure score 2.77 · Achievement 2.77 · Improvement 0
Total nurse turnover
0
Baseline 53.85% · Performance 70.59% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.43
Baseline 2.49 hours · Performance 3.13 hours · Measure score 1.43 · Achievement 0 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 9.23% · Lower 95% interval 6.93% |
| Discharge to community | 37.12% |
50.57%
13.5 pts worse
|
Worse than the National Rate · Eligible stays 62 · Observed rate 29.03% · Lower 95% interval 27.53% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 38.71% |
53.69%
15 pts worse
|
Numerator 12 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 9.52% |
2.29%
7.2 pts worse
|
Numerator 4 · Denominator 42 · Adjusted rate 9.63% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 6.75% |
8.2%
1.4 pts worse
|
Numerator 11 · Denominator 163 |
| Staff flu vaccination coverage | 57.28% |
42%
15.3 pts better
|
Numerator 59 · Denominator 103 |
| Discharge function score | 38.71% |
56.45%
17.7 pts worse
|
Numerator 12 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.78% |
25.2%
9.6 pts better
|
Numerator 8 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
95.7%
0.4 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.2% · Q3 95.9% · Q4 94.1% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.1% |
95.0%
6.9 pts worse
|
95.5%
7.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.5% · Q3 6.1% · Q4 5.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
4.9%
1.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 9.1% · Q3 4.7% · Q4 8.9% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
16.6%
0.8 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 18.2% · Q3 18.6% · Q4 13.0% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
16.7%
7.3 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 5.7% · Q3 8.8% · Q4 8.8% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.5% |
21.1%
4.4 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
17.3%
5.6 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 20.0% · Q3 14.6% · Q4 18.2% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.3%
0.9 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.8% · Q3 0.0% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
3.0%
0.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.8% · Q3 2.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
25.5%
2.7 pts better
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.8% · Q3 33.4% · Q4 17.8% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.5%
2.3 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 11.4% · Q3 9.1% · Q4 3.4% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.3% |
86.8%
12.5 pts worse
|
81.7%
7.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 74.5% · Q3 67.3% · Q4 70.0% · 4Q avg 74.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
15.0%
1 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 18.8% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.3% |
82.2%
22.9 pts worse
|
79.7%
20.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.6% |
22.7%
8.1 pts better
|
23.9%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 15.6% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-24 · Fire 2023-05-24
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-05-25 · Fire 2022-05-25
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-10
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-07-10
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-10
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-10
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-07-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-07-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-07-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-07-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-10
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-08-05
F · Potential for more than minimal harm
2023-05-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-05-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-07
C · Minimal harm
2023-05-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-07
F · Potential for more than minimal harm
2022-05-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-26
E · Potential for more than minimal harm
2022-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-15
E · Potential for more than minimal harm
2022-05-25
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-06-16
E · Potential for more than minimal harm
2022-05-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-25
E · Potential for more than minimal harm
2022-05-25
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-05-25
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-25
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-25
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-27
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-22
C · Minimal harm
2025-03-27
F846 · Administration Deficiencies
Health
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Corrected 2025-04-22
D · Potential for more than minimal harm
2024-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-13
G · Actual harm
2024-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-07-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Not marked corrected
D · Potential for more than minimal harm
2024-07-10
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-05-09
E · Potential for more than minimal harm
2023-11-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-11-27
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-11-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-08-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-17
F887 · Infection Control Deficiencies
Health
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.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-05-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-03-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-14
D · Potential for more than minimal harm
2022-05-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-25
Penalties and ownership
What sits behind the stars
$9,113
2025-03-27
Fine
Fine · fine $9,113
Fine
Ownership
Chwala, Nicole
Operational/Managerial Control · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Schleif, Terry
Corporate Director · Individual
Suhs, Kim
Corporate Director · Individual
Suhs, Kim
Corporate Officer · Individual
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Avina of Fond du Lac
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2-star overall rating with 2-star inspections with $7,446 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
St Francis Home
Fond Du Lac, WI
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Avina on Division
Fond Du Lac, WI
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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