The maintenance director told inspectors during a July interview that some of the nursing home's plumbing is more than 100 years old. His solution: "Continuously run H2O through" and "Don't allow H2O to sit in old lines."
But the facility's own risk management plan revealed gaps in that approach.
Federal inspectors found the nursing home failed to adequately prevent Legionella and other dangerous waterborne pathogens from growing in its building water systems. The Centers for Medicare and Medicaid Services cited the facility for water management deficiencies that posed potential harm to residents.
Legionella bacteria can cause a severe form of pneumonia called Legionnaires' disease, which is particularly dangerous for elderly residents in nursing homes. The bacteria thrive in warm water systems and can spread through plumbing, showers, and other water outlets.
The facility's own risk assessment identified multiple problem areas. Third-floor outlets were "poorly maintained, not used" and posed a "high" risk because "drains collect/H2O sits." The maintenance director said they now flush drains weekly, down from the previous practice of flushing toilets and drains twice weekly.
Hot water storage presented another concern. The facility rated temperature control as "medium" risk, noting that "temps may be too low." The maintenance director explained his approach: "will test random rooms on each floor monthly for hot H2O temps. 120 is what state allows & I usually keep it at 112. & check main H2O heater daily & kept 140 deg for kitchen & floors 110-120."
Those temperatures fall short of recommendations for preventing Legionella growth, which typically requires water heated to at least 140 degrees Fahrenheit in storage tanks.
The facility's incoming water supply also raised red flags. City water arrives with low chlorine levels, which the nursing home rated as "medium" risk. Their proposed solution was to "install chlorinator @ campus," but they noted that "City FDL controls H2O tx before gets to campus."
Inspectors discovered the facility's last comprehensive environmental assessment for Legionella was completed more than a year and a half ago, on January 10, 2023. This gap in monitoring occurred despite the facility's own identification of high-risk areas throughout the building.
The third floor presented particular challenges. Unused showers on that level required weekly flushing, according to the maintenance director. Water fountains that once served the lobby and each floor had been "disconnected from main H2O source," eliminating potential sources of stagnant water but also reducing resident access to drinking water.
The facility's water management plan included quarterly testing of emergency water systems, including sprinkler head flow tests. Records showed the most recent test occurred on December 21, 2022, nearly seven months before the inspection.
Ice machines remained in operation throughout the facility, though inspectors noted no specific concerns with their maintenance or water supply.
The nursing home's approach to monitoring hot water temperatures lacked consistency. While the maintenance director claimed to check the main water heater daily, inspectors found no formal log documenting these temperature checks. The facility acknowledged this gap, with inspectors noting a "need log for monitoring hot H2O temp."
Federal regulations require nursing homes to assess their water systems for Legionella risks and implement control measures based on nationally accepted standards from organizations like the CDC and Environmental Protection Agency. The standards recognize that elderly residents face heightened vulnerability to waterborne infections.
The facility's risk management plan used a scoring system rating hazards as low, moderate, high, or very high. Multiple systems received medium to high ratings, indicating significant potential for bacterial growth and spread.
Water stagnation emerged as a recurring theme in the facility's risk assessment. Old pipes, unused outlets, and infrequently accessed areas all created conditions where harmful bacteria could multiply. The maintenance director's weekly flushing protocol represented an attempt to address these risks, but inspectors questioned whether the measures went far enough.
The nursing home's water management deficiencies reflect broader challenges facing aging facilities across the country. Buildings constructed decades or centuries ago often lack the modern infrastructure needed to prevent waterborne disease outbreaks.
For Fond du Lac Lutheran Home's residents, the consequences of inadequate water safety measures could prove severe. Legionnaires' disease kills 10 percent of those who contract it, with elderly individuals facing even higher mortality rates.
The facility must now develop and implement a comprehensive plan to address the identified water management deficiencies. This includes establishing proper temperature controls, improving monitoring protocols, and ensuring adequate disinfection throughout the building's complex water systems.
The century-old pipes will likely remain, continuing to pose risks that require constant vigilance and more robust control measures than the facility currently employs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fond Du Lac Lutheran Home from 2024-07-10 including all violations, facility responses, and corrective action plans.