Fond Du Lac Lutheran Home

Penalties

• Mar 27, 2025 — Fine ($9,113)

Inspection findings

1. May 14, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Jun 3, 2026 · CMS health inspection

2. Sep 4, 2025 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Sep 23, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Sep 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Oct 25, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Oct 17, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 21, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0500 Services Deficiencies

     Meet other general requirements that are deficient.

     Corrected Sep 23, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 23, 2025 · CMS fire safety

3. Mar 27, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0584 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.

     Corrected Apr 22, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 22, 2025 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0846 Administration Deficiencies

     Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.

     Corrected Apr 22, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0947 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.

     Corrected Apr 22, 2025 · CMS health inspection

4. Dec 19, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Jan 13, 2025 · CMS health inspection

5. Sep 24, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 22, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Oct 17, 2024 · CMS health inspection

6. Jul 10, 2024 Fire Safety · 42 findings
   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Sep 11, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0029 Emergency Preparedness Deficiencies

     Develop a communication plan.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 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.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     CMS health inspection

   • Not serious Scope/severity D

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0700 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.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Dec 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0751 Miscellaneous Deficiencies

     Have restrictions on the use of flammable curtains.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Aug 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Aug 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Aug 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0925 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that sources of ignition are removed from patients receiving respiratory therapy.

     Corrected Aug 5, 2024 · CMS fire safety

7. Apr 10, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0726 Nursing and Physician Services Deficiencies

     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.

     Corrected May 9, 2024 · CMS health inspection

8. Nov 27, 2023 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     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.

     Corrected Dec 27, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 27, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 27, 2023 · CMS health inspection

9. Aug 3, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 1, 2023 · CMS health inspection

10. May 24, 2023 Fire Safety · 19 findings
    • Not serious Scope/severity F

      E0004 Emergency Preparedness Deficiencies

      Develop and maintain an Emergency Preparedness Program (EP).

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity D

      F0554 Resident Rights Deficiencies

      Allow residents to self-administer drugs if determined clinically appropriate.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0585 Resident Rights Deficiencies

      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.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0725 Nursing and Physician Services Deficiencies

      Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0883 Infection Control Deficiencies

      Develop and implement policies and procedures for flu and pneumonia vaccinations.

      Corrected Jul 7, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0211 Egress Deficiencies

      Keep aisles, corridors, and exits free of obstruction in case of emergency.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0300 Egress Deficiencies

      Meet other general requirements that are deficient.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Jul 7, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Jul 7, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• KAYMEN, STANLEY — operational/managerial control, NOT APPLICABLE, since 01/13/2023
• KAYMEN, STANLEY — adp of the snf, NOT APPLICABLE, since 03/03/2026
• MARKS, JULIE — corporate director, NOT APPLICABLE, since 09/16/2025
• MARKS, JULIE — corporate officer, NOT APPLICABLE, since 09/16/2025
• MARKS, JULIE — adp of the snf, NOT APPLICABLE, since 09/16/2025
• MARKS, JULIE — operational/managerial control, NOT APPLICABLE, since 09/16/2025
• MAUTHE, MATTHEW — adp of the snf, NOT APPLICABLE, since 08/01/2016
• MAUTHE, MATTHEW — corporate officer, NOT APPLICABLE, since 08/01/2016
• MAUTHE, MATTHEW — operational/managerial control, NOT APPLICABLE, since 08/01/2016
• SCHLEIF, TERRY — corporate director, NOT APPLICABLE, since 01/01/2016
• SUHS, KIM — corporate director, NOT APPLICABLE, since 01/01/2015
• WEBER, LISA — adp of the snf, NOT APPLICABLE, since 01/01/2014
• WEBER, LISA — operational/managerial control, NOT APPLICABLE, since 01/01/2014
• ILLUMINUS INC — operational/managerial control, NOT APPLICABLE, since 08/01/2016
• ILLUMINUS INC — adp of the snf, NOT APPLICABLE, since 11/16/2025
• LUTHERAN HOMES AND HEALTH SERVICES, INC. — 5% or greater direct ownership interest, 100%, since 09/19/2000
• LUTHERAN HOMES AND HEALTH SERVICES, INC. — operational/managerial control, NOT APPLICABLE, since 02/09/2005