01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-04 | 4 | 2025-09-04 | 10 |
| Cycle 2 | 2024-07-10 | 22 | 2024-07-10 | 27 |
| Cycle 3 | 2023-05-24 | 17 | 2023-05-24 | 9 |
CMS CCN 5256552026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Fond Du Lac Lutheran Home
244 N Macy St · Fond Du Lac, WI 54935 · Fond Du Lac County
Certified beds85CMS provider file
Recent citation rows89current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
89 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 16 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-14 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2025-09-04 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-09-232025-09-04 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-09-04 · HEALTHF0553Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Correction field: Deficient, Provider has date of correction · 2025-10-252025-09-04 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-10-252025-09-04 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-252025-09-04 · FIREK0223Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-09-182025-09-04 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-10-172025-09-04 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-11-212025-09-04 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-09-302025-09-04 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-09-222025-09-04 · FIREK0500Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2025-09-232025-09-04 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-09-222025-09-04 · FIREK0712Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-09-232025-03-27 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2025-03-27 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2025-03-27 · HEALTHF0846Severity C · widespread; potential for minimal harm
Administration Deficiencies
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2025-03-27 · HEALTHF0947Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2024-12-19 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-01-13 · complaint2024-09-24 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-10-22 · complaint2024-09-24 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-10-17 · complaint2024-07-10 · FIREE0007Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address patient/client population and determine types of services needed.
Correction field: Deficient, Provider has date of correction · 2024-08-052024-07-10 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Waiver has been granted · 2024-09-112024-07-10 · FIREE0029Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop a communication plan.
Correction field: Deficient, Provider has date of correction · 2024-08-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-03-27 | Fine | $9,113 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LUTHERAN HOMES AND HEALTH SERVICES, INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 09/19/2000
- MARKS, JULIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/16/2025
- SCHLEIF, TERRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
- SUHS, KIMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- MARKS, JULIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/16/2025
- MAUTHE, MATTHEWIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2016
- ILLUMINUS INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2016
- LUTHERAN HOMES AND HEALTH SERVICES, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/09/2005
- KAYMEN, STANLEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/13/2023
- MARKS, JULIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/16/2025
- MAUTHE, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2016
- WEBER, LISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2014
- ILLUMINUS INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/16/2025
- KAYMEN, STANLEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/03/2026
- MARKS, JULIEIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/16/2025
- MAUTHE, MATTHEWIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/01/2016
- WEBER, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2014
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.57per resident day
RN hours0.83per resident day
Weekend nurse hours3.17per resident day
Staff turnover59.3%CMS reported field
06 / LOCAL RECORDS
Open the Fond Du Lac ledger →Other published facilities nearby
Avina Of Fond Du Lac50 beds · CMS overall 2/562 citation rowsAvina On Division50 beds · CMS overall 1/571 citation rowsEdenbrook Of Fond Du Lac90 beds · CMS overall 4/536 citation rowsHarbor Haven Health & Rehabilitation85 beds · CMS overall 5/521 citation rowsSt Francis Home90 beds · CMS overall 3/547 citation rows