Fond Du Lac Lutheran Home

F-F880

Water Management: INTV [NAME] Maintenance Director 07/10/24 11:12 AM:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 525655 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525655 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fond Du Lac Lutheran Home 244 N Macy St Fond Du Lac, WI 54935

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -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 Level of Harm - Minimal harm or potential for actual harm Through interview (or record review as necessary), determine whether the facility has:

Residents Affected - Few Assessed (e.g., description of the building water systems using text and flow diagrams) where Legionella and other opportunistic waterborne

pathogens can grow and spread>>Reviewed Risk Management Plan for Legionella Control>>risk analysis done w scoring (low, mod, high, very high). Have a H2O flow diagram.

Measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on

nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency or EPA). For example, control measures can include visible inspections, disinfectant, temperature control (that may require mixing valves to prevent scalding);

System component Pot Hazardous event Risk score Poss Control Measures Control Procedures

-Incoming H2O low chlorine med install chlorinator @ campus City FDL controls H2O tx before gets to campus

-Hot H2O storage Temp may be too low med temps measured daily turn up thermostat if too low/adjust temp

when stored

-Cold H2O storage n/a cold H2o on demand- no storage tanks used

-Pipework/plumbing some piping > 100 y.o high Continuously run H2O through Don't allow H2O to sit in old lines

-Outlets poorly maintained, not used

outlets- 3rd floor high drains collect/H2O sits Flush toilets & flush drains 2x weekly>>now doing

drains weekly

--legionella environmental assessment form last completed 1/10/23--emergency H2O ie sprinkler head flow tests Yes done quarterly 12/21/22, no fountains. have ice machines

* need log for monitoring hot H2O temp: reviewed no concerns

* areas not used, how often flushed>> 3rd FLR now doing weekly; unused Showers on 3rd are flushed weekly as well. Had H2O fountains in lobby & one on ea floor were disconnected from main H2O source.

*is there routine process to run faucets, showers, & [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 525655