All citations for Fond du Lac Lutheran Home
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
September 4, 2025
Showing 1 to 25 of 88 citations
Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (April 22, 2025).
Harm to a resident
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (October 17, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (October 25, 2025).
No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
The home gave a date the problem would be corrected (September 23, 2025).
No harm, with potential for more than minimal harm
Establish emergency prep training and testing.
The home gave a date the problem would be corrected (September 24, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (October 17, 2025).
No harm, with potential for more than minimal harm
Address patient/client population and determine types of services needed.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Develop Emergency Preparedness policies and procedures.
A waiver was granted (September 11, 2024).
No harm, with potential for more than minimal harm
Develop a communication plan.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Provide family notifications of emergency plan.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Implement emergency and standby power systems.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Properly select, install, inspect, or maintain portable fire extinguishes.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
A waiver was granted (August 26, 2024).
No harm, with potential for more than minimal harm
Have restrictions on the use of portable space heaters.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Have a battery powered remote alarm panel in a location accessible by operating personnel.
A waiver was granted (August 30, 2024).
No harm, with potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
The home gave a date the problem would be corrected (August 6, 2024).
No harm, with potential for more than minimal harm
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
The home gave a date the problem would be corrected (August 5, 2024).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.