Fond du Lac Lutheran Home

Nursing Home · Fond du Lac, WI

CMS overall rating 3/5 Non profit - Corporation

CMS certification number525655

Contact & location

244 N Macy St
Fond du Lac, WI 54935
Fond Du Lac County
Phone
(920) 921-9520
ZIP code
54935 – all care providers

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Facility details

Certified beds
85
Residents per day
54.9 (65% occupied)
Ownership
Non profit - Corporation
Legal name
Fond Du Lac Lutheran Home, INC.
Chain
Illuminus (5 facilities, avg 2.0★)
Medicare certified since
January 1, 2000
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 3/5
State avg 3.0
Health inspections★★★★★ 3/5
State avg 2.8
Staffing★★★★★ 2/5
State avg 3.6
Quality measures★★★★★ 2/5
State avg 3.0
Long-stay quality★★★★★ 4/5
Short-stay quality★★★★★ 1/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.57 (state 4.21 · U.S. 3.86)
Registered nurses (RN)
0.83 (state 0.99 · U.S. 0.69)
Licensed practical nurses
0.45 (state 0.64 · U.S. 0.86)
Nurse aides
2.29 (state 2.58 · U.S. 2.32)
Weekend total
3.17 (state 3.77 · U.S. 3.42)
Nursing staff turnover
59.3 (state 46.9 · U.S. 45.8)%
RN turnover
40.0 (state 39.7 · U.S. 42.9)%
Administrators who left
2 in the last year

Inspections

Last standard inspection
September 4, 2025
Health deficiencies (last cycle)
4.0 (state 9.5 · U.S. 9.3)
From complaints
1
Citations on record (3 years)
43 health · 37 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-05-14 Ensure that residents are fully informed and understand their health status, care and treatments.
F0552 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-10-25
2025-09-04 Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F0553 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-25
2025-09-04 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-25
2025-03-27 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-04-22
2025-03-27 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.
F0584 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-22
2025-03-27 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F0947 · Nursing and Physician Services Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-22
2025-03-27 Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
F0846 · Administration Deficiencies · complaint inspection		 C
No actual harm, potential for minimal harm		 Corrected 2025-04-22
2024-12-19 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-01-13
2024-09-24 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2024-10-17
2024-09-24 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0725 · Nursing and Physician Services Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 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.
F0550 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Give the resident's representative the ability to exercise the resident's rights.
F0551 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0691 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0700 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-07-10 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-06
2024-04-10 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-05-09
2024-04-10 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-05-09
2024-04-10 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.
F0726 · Nursing and Physician Services Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-05-09
2023-11-27 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-12-27
2023-11-27 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.
F0585 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-12-27
2023-11-27 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-12-27
2023-08-03 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0725 · Nursing and Physician Services Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0585 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07
2023-05-24 Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-07

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $9,113 in fines.

DateTypeAmount
2025-03-27Fine$9,113

Ownership & management

NameRoleSince
Lutheran Homes and Health Services, INC. (organization)5%+ Direct Ownership Interest · 100%
Illuminus INC (organization)Administrator · NOT APPLICABLE
Kaymen, Stanley (individual)Administrator · NOT APPLICABLE
Marks, Julie (individual)Administrator · NOT APPLICABLE
Mauthe, Matthew (individual)Administrator · NOT APPLICABLE
Weber, Lisa (individual)Administrator · NOT APPLICABLE
Marks, Julie (individual)Corporate Director · NOT APPLICABLE
Schleif, Terry (individual)Corporate Director · NOT APPLICABLE
Suhs, Kim (individual)Corporate Director · NOT APPLICABLE
Marks, Julie (individual)Corporate Officer · NOT APPLICABLE
Mauthe, Matthew (individual)Corporate Officer · NOT APPLICABLE
Illuminus INC (organization)Operational/managerial Control · NOT APPLICABLE
Kaymen, Stanley (individual)Operational/managerial Control · NOT APPLICABLE
Lutheran Homes and Health Services, INC. (organization)Operational/managerial Control · NOT APPLICABLE
Marks, Julie (individual)Operational/managerial Control · NOT APPLICABLE
Mauthe, Matthew (individual)Operational/managerial Control · NOT APPLICABLE
Weber, Lisa (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Fond du Lac Lutheran Home?

Fond du Lac Lutheran Home has a 3-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.0-star average in Wisconsin.

How many beds does Fond du Lac Lutheran Home have?

It has 85 certified beds and cares for about 55 residents per day.

Has Fond du Lac Lutheran Home been fined?

Yes. CMS lists 1 penalty totaling $9,113 in the last three years.

Who owns Fond du Lac Lutheran Home?

It is part of Illuminus and is classified as non profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Fond du Lac Lutheran Home?

(920) 921-9520. The facility is located at 244 N Macy St, Fond du Lac, WI 54935.

Other nursing homes in Fond du Lac

Compare all nursing homes in Fond du Lac, WI →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.