Report
TheVardellReport
Fond du Lac Lutheran Home
Skilled nursing facility and nursing facility
244 N Macy St
Fond du Lac, WI 54935
Report
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The Vardell Report.Fond du Lac Lutheran Home
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Fond du Lac, WI
- Record Period
- 2023–2026
- Source Documents
- 11
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 9 inspections from May 2023 to May 2026, state surveyors documented 42 findings at Fond du Lac Lutheran Home; 41 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
- Inspections
- 9
- 2023–2026, complaint and standard
- Findings
- 42
- Deficiencies cited by state inspectors
- Corrected
- 41
- Of 42 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 13 | 0 |
| 2024 | 4 | 21 | 1 |
| 2025 | 2 | 7 | 1 |
| 2026 | 1 | 1 | 0 |
What the Record Shows
- 41 of 42 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $9,113, its payment not published.
- 6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 4, 2025, recorded 3 findings (most serious: Level F).
What to Ask About
- Quality of Care, Cited in Four Inspections
- Accident Hazards and Supervision, Cited in Four Inspections
- Infection Control, Cited in Three Inspections
- Residents Taking Their Own Medication, Cited in Two Inspections
- Grievances, Cited in Two Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Investigating Alleged Violations, Cited in Two Inspections
- Help With Daily Living, Cited in Two Inspections
- Nursing Staff Levels, Cited in Two Inspections
- Continence and Catheter Care, No Recorded Correction
Report at a Glance
- Facility
- Fond du Lac Lutheran Home
- Address
- 244 N Macy St, Fond du Lac, WI 54935
- CMS Certification Number
- 525655
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 85
- Ownership
- Non profit - Corporation
- Record Window
- May 24, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 3, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
3 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Oct 25, 2025
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Oct 25, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 25, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Apr 22, 2025
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
- F846Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.Level CPotential for minimal harmCorrected Apr 22, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jan 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Oct 17, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 22, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
15 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Aug 6, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F700Try 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.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 6, 2024
Enforcement Action
Civil money penalty, $9,113 imposed March 27, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 10, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected May 9, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
3 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
10 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jul 7, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jul 7, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Four Inspections
Inspectors cited F684 in May 2023, November 2023, April 2024 and September 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F684 across all 9 inspections, oldest to newest - 2
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in May 2023, April 2024, July 2024 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F689 across all 9 inspections, oldest to newest - 3
Infection Control, Cited in Three Inspections
Inspectors cited F880 in November 2023, July 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F880 across all 9 inspections, oldest to newest - 4
Residents Taking Their Own Medication, Cited in Two Inspections
Inspectors cited F554 in May 2023 and July 2024. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F554 across all 9 inspections, oldest to newest - 5
Grievances, Cited in Two Inspections
Inspectors cited F585 in May 2023 and November 2023. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F585 across all 9 inspections, oldest to newest - 6
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in May 2023 and July 2024. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F609 across all 9 inspections, oldest to newest - 7
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in May 2023 and September 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F610 across all 9 inspections, oldest to newest - 8
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in May 2023 and July 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F677 across all 9 inspections, oldest to newest - 9
Nursing Staff Levels, Cited in Two Inspections
Inspectors cited F725 in May 2023 and July 2024. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424252526F725 across all 9 inspections, oldest to newest - 10
Continence and Catheter Care, No Recorded Correction
F690 was cited in July 2024. This citation covers continence care, catheter care and preventing urinary tract infections. The most serious was level D (no actual harm, potential for more). The July 2024 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
232324242424252526F690 across all 9 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in four inspections, most seriously at level G.
- 02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level J.
- 03
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
- 04
How do you decide whether a resident may keep and take their own medications?
Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.
- 05
How do we file a grievance, who answers it, and how quickly?
Grievances: cited in two inspections, most seriously at level D.
- 06
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
- 07
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level D.
- 08
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
- 09
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in two inspections, most seriously at level F.
- 10
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in one inspections, most seriously at level D. The July 10, 2024 citation has no recorded correction date.
- 11
What led to the 2025 fine, and has it been paid?
A $9,113 civil money penalty was imposed March 27, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection May 24, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Nov 27, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Apr 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jul 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Sep 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Dec 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Mar 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Sep 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection May 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 525655
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowMay 24, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before May 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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