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Fond du Lac Lutheran Home

244 N Macy St
Fond du Lac, WI 54935 · 9209219520 · Fond Du Lac County

CMS Star Ratings

Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★

Facility Facts

Certified beds85
OwnershipNon profit - Corporation
State rank#143

By the numbers

43
Health citations (3 cycles)
1
Immediate-jeopardy (J/K/L)
1
Actual-harm (G/H/I)
$9,113
Federal fines (CMPs)
The trend: Citations are trending down — 4 in the most recent cycle versus 17 two cycles ago.

Recent Health Citations

May 14, 2026 · Health survey · F-tag 0552
D — No actual harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Sep 4, 2025 · Health survey · F-tag 0880
D — No actual harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Sep 4, 2025 · Health survey · F-tag 0553
D — No actual harm
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Sep 4, 2025 · Health survey · F-tag 0812
F — No actual 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.
Mar 27, 2025 · Health survey · F-tag 0846
C — Cited
Administration Deficiencies
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Mar 27, 2025 · Health survey · F-tag 0947
D — No actual 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.
Mar 27, 2025 · Health survey · F-tag 0584
D — No actual 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.
Mar 27, 2025 · Health survey · F-tag 0689
J — 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.
Details
Correction status: Corrected Apr 22, 2025 — Deficient, Provider has date of correction
Inspection cycle: 2
Survey origin: Complaint investigation
Dec 19, 2024 · Health survey · F-tag 0607
D — No actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Sep 24, 2024 · Health survey · F-tag 0610
D — No actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Sep 24, 2024 · Health survey · F-tag 0684
G — Actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Details
Correction status: Corrected Oct 17, 2024 — Deficient, Provider has date of correction
Inspection cycle: 2
Survey origin: Complaint investigation
Jul 10, 2024 · Health survey · F-tag 0880
D — No actual harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Jul 10, 2024 · Health survey · F-tag 0761
D — No actual harm
Pharmacy Service Deficiencies
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.
Jul 10, 2024 · Health survey · F-tag 0755
D — No actual harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Jul 10, 2024 · Health survey · F-tag 0700
D — No actual harm
Quality of Life and Care Deficiencies
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.
Jul 10, 2024 · Health survey · F-tag 0691
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Jul 10, 2024 · Health survey · F-tag 0690
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Jul 10, 2024 · Health survey · F-tag 0689
D — No actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jul 10, 2024 · Health survey · F-tag 0677
D — No actual harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Jul 10, 2024 · Health survey · F-tag 0656
D — No actual harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Showing the 20 most recent citations. View the full inspection record on CMS Care Compare →

More facilities in Wisconsin →

How to read this page. Star ratings and citation counts come from the Centers for Medicare & Medicaid Services (CMS) Care Compare August 2026 dataset, covering the three most recent inspection cycles. Scope/severity letters: D–F no actual harm, G–I actual harm, J–L immediate jeopardy to resident health or safety.

Source: CMS Care Compare, August 2026 dataset. Updated quarterly. Figures come from public CMS records; contact info@theskilledreport.com for corrections.