Fond Du Lac Lutheran Home
244 N Macy St, Fond Du Lac, WI 54935 · Fond Du Lac County · 85 certified beds · avg 55 residents/day · certified since Jan 1, 2000
Part of chain: ILLUMINUS (5 facilities, chain avg rating 2.0★)
3/5
Health inspection rating (on-site)
2
Serious findings on record
$9,113
Fines, last 3 years
3.42
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 27, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 24, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 17, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (43)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 14, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Sep 4, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 27, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Mar 27, 2025 | C · Minimal risk, facility-wide | The facility did not have policies ensuring that, if it ever closes, the administrator carries out all required steps to protect residents through the closure. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 24, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 24, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 10, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Nov 27, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 27, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Nov 27, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 24, 2023 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 24, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 14 | 0 | F |
| 2024 | 21 | 1 | G ▲ |
| 2025 | 7 | 1 | J ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,113.
| Date | Type | Amount / length |
|---|---|---|
| Mar 27, 2025 | Fine | $9,113 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.42 | 4.29 | 3.95 | bottom 20% in Wisconsin; bottom 32% in the U.S. |
| Registered Nurse hours | 0.80 | 1.01 | 0.69 | bottom 32% in Wisconsin; top 28% in the U.S. |
| Weekend total nurse staffing | 3.04 | 3.84 | 3.50 | bottom 21% in Wisconsin; bottom 33% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.50 | 0.68 | 0.48 | bottom 33% in Wisconsin; top 33% in the U.S. |
| Total nursing staff turnover (%) | 59.3 | 46.9 | 45.8 | bottom 20% in Wisconsin; bottom 17% in the U.S. |
| RN turnover (%) | 40.0 | 39.7 | 42.9 | bottom 48% in Wisconsin; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.57, RN 0.83, weekend 3.17. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lutheran Homes and Health Services, INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/19/2000 |
| Illuminus INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2016 |
| Illuminus INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/16/2025 |
| Kaymen, Stanley | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/13/2023 |
| Kaymen, Stanley | Individual | ADP of the SNF | NOT APPLICABLE | 03/03/2026 |
| Lutheran Homes and Health Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/09/2005 |
| Marks, Julie | Individual | Corporate Director | NOT APPLICABLE | 09/16/2025 |
| Marks, Julie | Individual | Corporate Officer | NOT APPLICABLE | 09/16/2025 |
| Marks, Julie | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/16/2025 |
| Marks, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 09/16/2025 |
| Mauthe, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2016 |
| Mauthe, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2016 |
| Mauthe, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2016 |
| Schleif, Terry | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Suhs, Kim | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Weber, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2014 |
| Weber, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How are residents and families included in care plan meetings, and how often do those meetings happen?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What specific training do your nurse aides complete in dementia care and abuse prevention, and how often is it refreshed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avina of Fond Du Lac | 0.3 mi | Fond Du Lac, WI | ★★☆☆☆ | 2/5 | |
| St Francis Home | 0.9 mi | Fond Du Lac, WI | ★★★☆☆ | 3/5 | |
| Avina on Division | 1.2 mi | Fond Du Lac, WI | ★☆☆☆☆ | 1/5 | |
| Harbor Haven Health & Rehabilitation | 1.2 mi | Fond Du Lac, WI | ★★★★★ | 5/5 | |
| Edenbrook of Fond Du Lac | 1.7 mi | Fond Du Lac, WI | ★★★★☆ | 4/5 | |
| Hope Health and Rehab | 13.6 mi | Lomira, WI | ★★★★★ | 4/5 | |
| Bethel Home | 17.4 mi | Oshkosh, WI | ★★★★★ | 4/5 | |
| Edenbrook of Oshkosh | 18.0 mi | Oshkosh, WI | ★★★☆☆ | 3/5 | |
| Evergreen Health Center | 18.1 mi | Oshkosh, WI | ★★★★☆ | 4/5 | |
| Eden Rehab Suites and Green House Homes | 18.5 mi | Oshkosh, WI | ★★☆☆☆ | 2/5 | |
| Complete Care at Christian Home LLC | 18.8 mi | Waupun, WI | ★★☆☆☆ | 2/5 | |
| Whispering Pines Nursing and Rehab, LLC | 19.9 mi | Ripon, WI | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
All facilities in Fond Du Lac →
Facility data as of CMS processing date 2026-08-01. CCN 525655.