Nursing homeActive
Fond du Lac Lutheran Home
244 N Macy St, Fond du Lac, WI 54935920921952085 certified beds · 55 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
43
● 1● 40● 2
Penalties · 3 yrs
$9,113
1 fine
Last survey
2026-05-14
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 3
Staffing 2
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-14 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-09-04 | Standard | 030 | CMS-2567 (Care Compare) | — |
| 2025-03-27 | Complaint | 121 | CMS-2567 (Care Compare) | — |
| 2024-12-19 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-09-24 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2024-07-10 | Standard | 0150 | CMS-2567 (Care Compare) | — |
| 2024-04-10 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-11-27 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-08-03 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-05-24 | Standard | 0100 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-03Record 525655-20260514-F552
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-25Record 525655-20250904-F553
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-10-25Record 525655-20250904-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-25Record 525655-20250904-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-04-22Record 525655-20250327-F689
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-22Record 525655-20250327-F584
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-22Record 525655-20250327-F947
F846Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2025-04-22Record 525655-20250327-F846
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-13Record 525655-20241219-F607
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-17Record 525655-20240924-F684
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-22Record 525655-20240924-F610
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F550
F551Give the resident's representative the ability to exercise the resident's rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F551
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F554
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F609
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 525655-20240710-F690
F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F691
F700Try 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F700
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F725
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F755
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 525655-20240710-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-09Record 525655-20240410-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-09Record 525655-20240410-F689
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-09Record 525655-20240410-F726
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-27Record 525655-20231127-F585
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-27Record 525655-20231127-F684
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-27Record 525655-20231127-F880
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-01Record 525655-20230803-F755
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F554
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F585
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F610
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F689
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F725
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-07Record 525655-20230524-F883
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-03-27 | Civil money penalty | $9,113 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.83
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day3.57
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours3.17
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover59%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Registered nurse turnover40%
Facility
Wisconsin
National
Wisconsin 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wisconsin | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.1% | 5.0% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 3.3% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 9.2% | 15.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.5% | 2.7% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 13.6% | 16.1% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.3% | 5.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 15.2% | 16.9% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Lutheran Homes And Health Services, Inc. Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Illuminus Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Kaymen, Stanley Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lutheran Homes And Health Services, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Marks, Julie Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mauthe, Matthew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Weber, Lisa Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Illuminus Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Kaymen, Stanley Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Marks, Julie Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Marks, Julie Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Marks, Julie Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mauthe, Matthew Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mauthe, Matthew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Schleif, Terry Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Suhs, Kim Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Weber, Lisa Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Illuminus — 5 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.
No county cost figures on file for Fond Du Lac.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Avina of Fond du Lac Fond du Lac | 0.3 mi | 2026-04-22 | 0261 |
| St Francis Home Fond du Lac | 0.9 mi | 2026-04-01 | 0260 |
| Harbor Haven Health & Rehabilitation Fond du Lac | 1.2 mi | 2025-04-23 | 020 |
| Avina on Division Fond du Lac | 1.2 mi | 2026-04-30 | 2243 |
| Edenbrook of Fond Du Lac Fond Du Lac | 1.7 mi | 2025-06-11 | 0111 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |