Fond Du Lac Lutheran HomeCMS ratings, inspections and fines
- Address
- 244 N Macy St, Fond Du Lac, WI 54935
- CCN
- 525655
- Ownership type
- Non-profit, corporation
- Certified beds
- 85
- Chain
- Illuminus
- Residents per day
- 55
- CMS flags
- None in the CMS record
Open the watch listCare Compare record (Medicare.gov)
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Fond Du Lac Lutheran Home an overall rating of 3 of 5 stars. The last standard survey was on 4 Sep 2025. The latest survey cycle has 4 health citations. The median for nursing homes in Wisconsin is 7. CMS lists 1 fine of $9,113 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Fond du Lac County median | Wisconsin median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 3 | 3.0 | 3.0 | 3.0 |
| Health inspection rating | 3 | 3.0 | 3.0 | 2.8 |
| Staffing rating | 2 | 3.0 | 4.0 | 2.9 |
| Quality measure rating | 2 | 3.0 | 3.0 | 3.6 |
A median is the middle value of the homes in the group: 7 homes in the county, 323 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Wisconsin median |
|---|---|---|---|
| Cycle 1 (latest) | 4 Sep 2025 | 4 | 7 |
| Cycle 2 | 10 Jul 2024 | 22 | 7 |
| Cycle 3 | No date | 17 | 6 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 |
Survey cycle 1 (latest): 4 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 14 May 2026 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Complaint investigation | 3 Jun 2026 |
| 4 Sep 2025 | F0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | Standard survey | 25 Oct 2025 |
| 4 Sep 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 25 Oct 2025 |
| 4 Sep 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 25 Oct 2025 |
Survey cycle 2: 22 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 27 Mar 2025 | F0584 | 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 | Complaint investigation | 22 Apr 2025 |
| 27 Mar 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 22 Apr 2025 |
| 27 Mar 2025 | F0846 | Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | C | Complaint investigation | 22 Apr 2025 |
| 27 Mar 2025 | F0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D | Complaint investigation | 22 Apr 2025 |
| 19 Dec 2024 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint investigation | 13 Jan 2025 |
| 24 Sep 2024 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 22 Oct 2024 |
| 24 Sep 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Complaint investigation | 17 Oct 2024 |
| 10 Jul 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0551 | Give the resident's representative the ability to exercise the resident's rights. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0690 | 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 | Standard survey | Deficient, Provider has no plan of correction |
| 10 Jul 2024 | F0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0700 | 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 | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0761 | 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. | D | Standard survey | 6 Aug 2024 |
| 10 Jul 2024 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 6 Aug 2024 |
Survey cycle 3: 17 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 10 Apr 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 9 May 2024 |
| 10 Apr 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 9 May 2024 |
| 10 Apr 2024 | F0726 | 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. | D | Complaint investigation | 9 May 2024 |
| 27 Nov 2023 | F0585 | 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 | Complaint investigation | 27 Dec 2023 |
| 27 Nov 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 27 Dec 2023 |
| 27 Nov 2023 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 27 Dec 2023 |
| 3 Aug 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 1 Sep 2023 |
| 24 May 2023 | F0554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0585 | 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 | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0610 | Respond appropriately to all alleged violations. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Standard survey | 7 Jul 2023 |
| 24 May 2023 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard survey | 7 Jul 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 27 Mar 2025 | Fine | $9,113 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Wisconsin median | Wisconsin average (CMS) |
|---|---|---|---|
| All nurse staff | 3.57 | 4.00 | 4.21 |
| Registered nurses (RN) | 0.83 | 0.90 | 0.99 |
| Licensed practical nurses (LPN) | 0.45 | 0.64 | |
| Nurse aides | 2.29 | 2.58 | |
| All nurse staff, weekends | 3.17 | 3.60 | 3.77 |
- Nurse staff turnover in a year
- 59.3%
- Nurse staff turnover, Wisconsin median
- 46.2%
- RN turnover in a year
- 40.0%
- Administrators who left in a year
- 2
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.6% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.5% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.5% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.3% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 23.1% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.1% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 9.2% | 14.4% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Non-profit, corporation
- Legal business name
- Fond Du Lac Lutheran Home, Inc.
- Chain
- Illuminus (5 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Lutheran Homes and Health Services, Inc. | 5% or greater direct ownership interest | 100% | 19 Sep 2000 |
| Illuminus Inc | Operational/managerial control | 1 Aug 2016 | |
| Lutheran Homes and Health Services, Inc. | Operational/managerial control | 9 Feb 2005 | |
| Illuminus Inc | Adp of the snf | 16 Nov 2025 |
The site shows organisations only. It does not show the names of persons.
Other homes in Fond du Lac County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Avina of Fond Du Lac | Fond Du Lac | 2 of 5 | 15 | $7,446 | 17 Jul 2025 | |
| St Francis Home | Fond Du Lac | 3 of 5 | 5 | $0 | 1 Apr 2026 | |
| Avina on Division | Fond Du Lac | 1 of 5 | 16 | $0 | 21 May 2025 | |
| Harbor Haven Health & Rehabilitation | Fond Du Lac | 5 of 5 | 0 | $0 | 23 Apr 2025 | |
| Edenbrook of Fond Du Lac | Fond Du Lac | 4 of 5 | 3 | $9,113 | 11 Jun 2025 | |
| Whispering Pines Nursing and Rehab, LLC | Ripon | 3 of 5 | 12 | $12,649 | 15 Jan 2025 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Fond Du Lac Lutheran Home (CCN 525655). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/fond-du-lac-lutheran-home-fond-du-lac-wi-525655/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Fond Du Lac Lutheran Home last inspected?
- The latest inspection with a citation in the CMS record was on 14 May 2026. It was a complaint investigation. It gave 1 citation. The standard survey before the last one was on 10 Jul 2024.
- Who operates Fond Du Lac Lutheran Home?
- The CMS record gives the ownership type as non-profit, corporation. CMS lists the home in the chain Illuminus. The CMS ownership file names Illuminus Inc and Lutheran Homes and Health Services, Inc. for operational or managerial control. This site does not show the names of persons.
- Is Fond Du Lac Lutheran Home a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 2 homes in Wisconsin as Special Focus Facilities and 10 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.