Nursing homes › Wisconsin › Fond Du Lac Lutheran Home
244 N Macy St, Fond Du Lac, WI 54935 · 9209219520 · 85 certified beds
Per CMS filings, this facility is affiliated with Illuminus, a group operating 5 facilities in 1 states. Group record: average rating 2.0/5, 0 abuse citation icons, 0 facilities on the Special Focus list, $522,517 in federal fines. This facility rates above its group average (2.0/5).
Total nurse staffing: 3.57 (Wisconsin median: 4.06). RN hours: 0.83. Weekend total: 3.17. Nursing staff turnover: 59%.
All-time on record: 45 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-14 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | complaint | 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. | F | Health | 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. | D | Health | corrected 2025-10-25 |
| 2025-09-04 | Provide and implement an infection prevention and control program. | D | Health | 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. | J | complaint | 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. | D | complaint | 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. | D | complaint | corrected 2025-04-22 |
| 2025-03-27 | Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | C | complaint | corrected 2025-04-22 |
| 2024-12-19 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | complaint | corrected 2025-01-13 |
| 2024-09-24 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | complaint | corrected 2024-10-17 |
| 2024-09-24 | Respond appropriately to all alleged violations. | D | complaint | 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. | E | Health | 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. | D | Health | corrected 2024-08-06 |
| 2024-07-10 | Give the resident's representative the ability to exercise the resident's rights. | D | Health | corrected 2024-08-06 |
| 2024-07-10 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Health | 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. | D | Health | corrected 2024-08-06 |
| 2024-07-10 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Health | 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. | D | Health | corrected 2024-08-06 |
| 2024-07-10 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | 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. | D | Health | 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. | D | Health | 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. | D | Health | 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. | D | Health | 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. | D | Health | 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. | D | Health | corrected 2024-08-06 |
| 2024-07-10 | Provide and implement an infection prevention and control program. | D | Health | corrected 2024-08-06 |
| 2024-04-10 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | 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. | D | complaint | 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. | D | complaint | corrected 2024-05-09 |
| 2023-11-27 | Provide and implement an infection prevention and control program. | E | complaint | 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. | D | complaint | corrected 2023-12-27 |
| 2023-11-27 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | 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. | D | complaint | corrected 2023-09-01 |
| 2023-07-17 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Health | corrected 2023-09-08 |
| 2023-07-17 | 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. | D | Health | corrected 2023-09-08 |
| 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. | F | Health | corrected 2023-07-07 |
| 2023-05-24 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Health | 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. | D | Health | corrected 2023-07-07 |
| 2023-05-24 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Health | corrected 2023-07-07 |
| 2023-05-24 | Respond appropriately to all alleged violations. | D | Health | corrected 2023-07-07 |
| Date | Type | Amount |
|---|---|---|
| 2025-03-27 | Fine | $9,113 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| LUTHERAN HOMES AND HEALTH SERVICES, INC. | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 09/19/2000 |
| MARKS, JULIE | Corporate Director | Individual | NOT APPLICABLE | since 09/16/2025 |
| SCHLEIF, TERRY | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2016 |
| SUHS, KIM | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2015 |
| MARKS, JULIE | Corporate Officer | Individual | NOT APPLICABLE | since 09/16/2025 |
| MAUTHE, MATTHEW | Corporate Officer | Individual | NOT APPLICABLE | since 08/01/2016 |
| ILLUMINUS INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 08/01/2016 |
| LUTHERAN HOMES AND HEALTH SERVICES, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 02/09/2005 |
| KAYMEN, STANLEY | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/13/2023 |
| MARKS, JULIE | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/16/2025 |
| MAUTHE, MATTHEW | Operational/Managerial Control | Individual | NOT APPLICABLE | since 08/01/2016 |
| WEBER, LISA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/01/2014 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 525655. Corrections: data@carerecords.org.