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 26 to 46 of 46 citations

No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (September 15, 2024).
No harm, with potential for more than minimal harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0362, 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
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of July 10, 2024. Found during a standard inspection.
A waiver was granted (December 24, 2024).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0511, Services 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 restrictions on the use of flammable curtains.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0751, 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
Have restrictions on the use of highly flammable decorations.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0753, 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 that sources of ignition are removed from patients receiving respiratory therapy.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0925, 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
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0211, Egress 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
Inspect, test, and maintain automatic sprinkler systems.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0353, Smoke 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
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke 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
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0521, Services 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
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0223, Egress Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (September 18, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (November 21, 2025).
No harm, with potential for more than minimal harm
Properly select, install, inspect, or maintain portable fire extinguishes.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0355, Smoke Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (September 30, 2025).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (September 22, 2025).
No harm, with potential for more than minimal harm
Meet other general requirements that are deficient.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0500, Services 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
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0521, Services Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (September 22, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0712, Miscellaneous 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
Have power receptacles that are properly grounded.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0912, 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
Meet other general requirements that are deficient.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0300, Egress 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 minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level C.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of May 24, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 7, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.