Federal inspection record · CMS data as of October 1, 2026
Fond du Lac Lutheran Home
244 N Macy St, Fond du Lac, WI · (920) 921-9520
- Certified beds
- 85
- Residents per day
- 50
- Ownership
- Non-Profit
- Chain
- Illuminus
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 1, 2000
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Fond du Lac Lutheran Home carries 71.75 inspection points. That is fewer than 45% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
42 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Everything else, by area of care
Quality of Life and Care12D
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- D
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.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights9D
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Give the resident's representative the ability to exercise the resident's rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
Freedom from Abuse, Neglect, and Exploitation6D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Respond appropriately to all alleged violations.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Nursing and Physician Services4F
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
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.
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Pharmacy Service2D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration1C
- C
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Resident Assessment and Care Planning1D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspection history
2025-09-04
4 health deficiencies · 10 fire-safety deficiencies
Top issue: Resident Rights (2 deficiencies)
2024-07-10
20 health deficiencies · 27 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2023-05-24
18 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 51 min of nursing staff time a day, 58 min of it from a registered nurse.
This home
3 h 51 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 59% of nursing staff and 55% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$9,113 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-27 | Fine | $9,113 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts better | 1.3 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts better | 1.3 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.5 pts worse | 95.5% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine8.1 pts worse | 87.5% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts better | 1.7% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.7 pts better | 1.3% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.4 pts better | 4.5% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.9 pts better | 13.9% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.7 pts better | 9.2% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened10 pts worse | 27.0% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.1 pts better | 13.7% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 1.6% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1 pts better | 1.7% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.9 pts better | 19.7% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.3 pts better | 4.6% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine14.3 pts worse | 72.6% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.1 pts worse | 15.7% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine28.7 pts worse | 53.5% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.2 pts worse | 24.7% | 22.5% | 23.4% |
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Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Lutheran Homes And Health Services, Inc. | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Illuminus Inc | Operational/Managerial Control · Organization | 0% | 11 facilities |
| Illuminus Inc | Adp Of The SNF · Organization | 0% | 11 facilities |
| Kaymen, Stanley | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Kaymen, Stanley | Adp Of The SNF · Individual | 0% | 2 facilities |
| Lutheran Homes And Health Services, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Marks, Julie | Corporate Director · Individual | 0% | 11 facilities |
| Marks, Julie | Corporate Officer · Individual | 0% | 11 facilities |
| Marks, Julie | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Marks, Julie | Adp Of The SNF · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Corporate Officer · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Adp Of The SNF · Individual | 0% | 11 facilities |
| Schleif, Terry | Corporate Director · Individual | 0% | 1 facilities |
| Suhs, Kim | Corporate Director · Individual | 0% | 1 facilities |
| Weber, Lisa | Operational/Managerial Control · Individual | 0% | 8 facilities |
| Weber, Lisa | Adp Of The SNF · Individual | 0% | 8 facilities |
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Fire safety
46 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke16F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Have an enclosure around a vertical opening shaft.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Provide properly protected cooking facilities.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E
Install corridor and hallway doors that block smoke.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- C
Have approved installation, maintenance and testing program for fire alarm systems.
Emergency Preparedness8F
- F
Establish emergency prep training and testing.
- F
Conduct risk assessment and an All-Hazards approach.
- F
Develop Emergency Preparedness policies and procedures.
- F
Develop a communication plan.
- F
Provide family notifications of emergency plan.
- F
Implement emergency and standby power systems.
- F
Address patient/client population and determine types of services needed.
- F
Develop and maintain an Emergency Preparedness Program (EP).
Miscellaneous7F
- D
Have simulated fire drills held at unexpected times.
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have restrictions on the use of portable space heaters.
- E
Have restrictions on the use of flammable curtains.
- E
Have restrictions on the use of highly flammable decorations.
- F
Have simulated fire drills held at unexpected times.
Egress5E
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E
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.
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Meet other general requirements that are deficient.
Gas, Vacuum, and Electrical Systems5F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- E
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- D
Have power receptacles that are properly grounded.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Services4E
- D
Meet other general requirements that are deficient.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Have properly installed electrical wiring and gas equipment.
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Construction1E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
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Other homes nearby
-
Avina of Fond du Lac
Fond du Lac, WI · Avina Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 7 min
- Fines
- $7,446
-
St Francis Home
Fond du Lac, WI · Ssm Health
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 33 min
- Fines
- $0
-
Avina on Division
Fond du Lac, WI · Avina Healthcare
★★★★★- Worst citation, 3 yrs
- L
- Nursing / resident / day
- 3 h 37 min
- Fines
- $58,210