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 50 of 88 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

  11. 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).

  12. 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).

  13. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 27, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 27, 2023).

  14. 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).

  15. 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).

  16. 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).

  17. 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).

  18. No harm, with potential for more than minimal harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0552, Resident Rights Deficiencies. Inspection of May 14, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 3, 2026).

  19. No harm, with potential for more than minimal harm

    Allow resident to participate in the development and implementation of his or her person-centered plan of care.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0553, Resident Rights Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2025).

  20. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of September 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2025).

  21. 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).

  22. 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).

  23. 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).

  24. 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).

  25. 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).

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.