Compiled from official CMS federal data
Fond du Lac Lutheran Home, Fond du Lac, WI — Violations & Inspection Reports
Does Fond du Lac Lutheran Home have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Fond du Lac Lutheran Home (CCN 525655), in Fond du Lac, WI, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 15 deficiencies; the most severe is rated E — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2024-07-10. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $9,113 in civil money penalties on file against the facility. The record also includes 6 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Dec 2024). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 6 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Dec 2024.
- 5 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Mar 2025.
- 1 pressure-ulcer care citation (F686) — the consumer term is "bedsores"; most recent May 2023.
- 14 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
CMS has $9,113 in civil money penalties on file against this facility.
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$9,113
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About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
41 more citations on file — Abuse & neglect 6 · Accidents & supervision 4 · Pressure ulcers 1 · Medication & pharmacy 3 · Resident rights 7 · Other citations 16 (expand)
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.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Respond appropriately to all alleged violations.
Provide and implement an infection prevention and control program.
Give the resident's representative the ability to exercise the resident's rights.
Allow residents to self-administer drugs if determined clinically appropriate.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Allow residents to self-administer drugs if determined clinically appropriate.
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.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Overall CMS star rating
This facility: 1 · CMS state average: 3.0
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
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Federal record
Fond du Lac Lutheran Home — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at Fond du Lac Lutheran Home to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?