Fond Du Lac Lutheran Home
Fond Du Lac, Fond Du Lac County, Wisconsin · CCN 525655 · Non-profit (Corporation) · part of Illuminus (5 facilities, chain average 2 stars)
CMS rates Fond Du Lac Lutheran Home 3 of 5 overall as of August 2026. 85 certified beds, 55 residents a day on average. 43 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $9,113.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 4 / 1 of 5 |
Staffing
| Total nurse staffing | 3.57165 hours per resident per day |
|---|---|
| Registered nurses | 0.83224 hours per resident per day |
| Weekend total | 3.17493 hours per resident per day |
| Nursing staff turnover | 59.3% (registered nurses 40%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-05-14 complaint survey |
Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2025-09-04 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-10-25 |
| 2025-09-04 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-25 |
| 2025-09-04 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-25 |
| 2025-03-27 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-04-22 |
| 2025-03-27 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-22 |
| 2025-03-27 complaint survey |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-22 |
| 2025-03-27 complaint survey |
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. Administration Deficiencies · tag F0846 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-04-22 |
| 2024-12-19 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-13 |
| 2024-09-24 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-10-17 |
| 2024-09-24 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-22 |
| 2024-07-10 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Give the resident's representative the ability to exercise the resident's rights. Resident Rights Deficiencies · tag F0551 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2024-07-10 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | 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. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-10 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-04-10 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-09 |
| 2024-04-10 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-09 |
| 2024-04-10 complaint survey |
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. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-09 |
| 2023-11-27 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-12-27 |
| 2023-11-27 complaint survey |
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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-27 |
| 2023-11-27 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-27 |
| 2023-08-03 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-01 |
| 2023-05-24 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | 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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
| 2023-05-24 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-07 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-27 | Fine | $9,113 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Lutheran Homes And Health Services, Inc. Organization | 5% or greater direct ownership interest | 100% | 2000-09-19 |
| Illuminus Inc. Organization | adp of the snf | — | 2025-11-16 |
| Illuminus Inc. Organization | operational/managerial control | — | 2016-08-01 |
| Lutheran Homes And Health Services, Inc. Organization | operational/managerial control | — | 2005-02-09 |
| Kaymen, Stanley Individual | adp of the snf | — | 2026-03-03 |
| Marks, Julie Individual | adp of the snf | — | 2025-09-16 |
| Mauthe, Matthew Individual | adp of the snf | — | 2016-08-01 |
| Weber, Lisa Individual | adp of the snf | — | 2014-01-01 |
| Marks, Julie Individual | corporate director | — | 2025-09-16 |
| Schleif, Terry Individual | corporate director | — | 2016-01-01 |
| Suhs, Kim Individual | corporate director | — | 2015-01-01 |
| Marks, Julie Individual | corporate officer | — | 2025-09-16 |
| Mauthe, Matthew Individual | corporate officer | — | 2016-08-01 |
| Kaymen, Stanley Individual | operational/managerial control | — | 2023-01-13 |
| Marks, Julie Individual | operational/managerial control | — | 2025-09-16 |
| Mauthe, Matthew Individual | operational/managerial control | — | 2016-08-01 |
| Weber, Lisa Individual | operational/managerial control | — | 2014-01-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Fond Du Lac Lutheran Home.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Fond Du Lac County.