Fond du Lac Lutheran Home has a 1-star overall rating, with 2 stars for health inspections, 3 stars for staffing, and 1 star for quality measures. It reports 3.77 nurse staffing hours per resident per day versus the 4.1 federal benchmark, and it had $9,113 in fines in the last 24 months with a recent federal penalty.
Last inspection: March 27, 2025Penalties, last 24 months: $9,113recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.765.
Staffing detail
Registered nurses
0.78
Licensed practical nurses
0.46
Nurse aides
2.53
Weekend nursing
3.36
Hours per resident per day.
Total staff turnover: 48%
Registered nurse turnover: 50%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
7.6%Steady
Residents with a fall causing major injury
5.2%Improving
Residents with pressure ulcers (bedsores)
7.6%Improving
Residents with a urinary tract infection
1.6%Improving
Residents who lost too much weight
5.9%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
17.5%Improving
Residents whose ability to walk got worse
23.1%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
16.3%Improving
Short-stay residents newly given an antipsychotic
0%Steady
Residents with a long-term catheter
1.6%Worsening
Residents with new or worsening incontinence
21.2%Improving
Residents with depressive symptoms
0.6%Worsening
Long-stay residents given the seasonal flu vaccine
88.1%Steady
Long-stay residents given the pneumonia vaccine
95.4%Worsening
Short-stay residents given the seasonal flu vaccine
59.3%Steady
Short-stay residents given the pneumonia vaccine
72.6%Improving
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited September 2024 — isolated incident, actual harm.
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F-Tag 684 — 42 CFR §483.25 — S/S: G
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited May 2023 — widespread issue, potential for harm.
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F-Tag 725 — 42 CFR §483.35 — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited November 2023 — limited pattern, potential for harm.
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F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The home failed to ensure residents had a safe, clean, comfortable, homelike environment and daily care supports were provided safely. Cited March 2025 — isolated incident, potential for harm.
View the original federal record
F-Tag 584 — 42 CFR §483.10 — S/S: D
Recent history
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
PENALTY
A federal fine of $9,113 was recorded.
INSPECTION
Health inspection found 4 health deficiencies.
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INSPECTION
Health inspection found 1 health deficiency.
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INSPECTION
Health inspection found 2 health deficiencies.
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Penalties & enforcement
On record with Medicare: 1 fine · $9,113 in total fines.
Federal fine
Mar 27, 2025
$9,113
Operator & ownership
Ownership
Non profit - Corporation
Chain
Part of ILLUMINUS · 5 homes · 1 stars avg
Occupancy
50.9 residents on an average day (60% of 85 beds)
Resident voice
Resident council
Medicare history
Certified for 26 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.