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.

Back to Fond du Lac Lutheran Home

Last standard health inspection on record

September 4, 2025

Showing 1 to 25 of 46 citations

No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0007, Emergency Preparedness Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0013, Emergency Preparedness Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (September 11, 2024).
No harm, with potential for more than minimal harm
Develop a communication plan.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0029, Emergency Preparedness Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0035, Emergency Preparedness Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0041, Emergency Preparedness Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0346, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0354, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0355, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0781, Miscellaneous Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0916, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (August 30, 2024).
No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of May 24, 2023. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 24, 2023. Found during a standard inspection.
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.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 24, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0132, Construction Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0225, Egress Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Have an enclosure around a vertical opening shaft.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0311, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (September 20, 2024).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (September 3, 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.