Failure to Maintain On-Site Emergency Water Supply
Summary
The facility failed to adhere to its procedure for maintaining an adequate emergency water supply, which had the potential to affect all 61 residents. During an interview with the Director of Nursing and the Director of Maintenance, it was confirmed that the facility did not have an emergency water supply on site, as it was kept off site. A review of the facility's undated policy titled 'Emergency Water Supply' indicated that the facility was supposed to provide three days of food and water for staff or other persons who would stay at the facility during an emergency. Additionally, the policy stated that the water should be stored in the old assembly hall supply closet.
Penalty
Resources
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Emergency water supply was not properly maintained onsite. The FSM told the surveyor the water was not in the building, and the Administrator stated they did not think emergency water was needed onsite. When the supply was finally shown, the surveyor observed crushed cases, opened and uncapped jugs, empty jugs, white powder on some cases, and water with outdated best-by dates. The amount on hand was only about 250 to 300 gallons and was confirmed by the Administrator and FSM to be insufficient for 3 days for the resident census.
The facility did not maintain an adequate emergency water supply as required by its policy, with only a 3-day supply of bottled water for drinking and cooking and two out of four hot water heaters not operational. The Administrator confirmed there was not enough water to meet the needs of all residents and staff for a 3-day emergency period.
Facility staff did not have written procedures to ensure the availability of both drinkable and non-drinkable water in the event of a loss of normal water supply. The Administrator described a verbal plan for water provision, but this was not documented, and emergency water storage was insufficient. The agreement with a water delivery company did not guarantee supply during high demand and did not address non-drinkable water needs.
The facility failed to maintain an adequate emergency water supply, storing only 125 gallons instead of the required 255 gallons for 85 residents. Additionally, the stored water was expired, and the hot water tanks were deemed unsafe for drinking. The NHA confirmed the lack of a safe emergency water supply.
The facility did not maintain an adequate supply of safe, unexpired potable water for all residents in the event of a water outage, due to lack of a clear policy and confusion among staff regarding responsibility for monitoring water expiration dates. Only a small portion of the stored water was drinkable, falling short of the industry standard for emergency preparedness.
The facility did not follow its procedures for rotating emergency water supplies, resulting in expired water being stored in essential areas. Observations revealed that multiple boxes of water on Nursing Unit 1 and in the main kitchen were past their best by dates, with no evidence of regular rotation as per policy. Staff interviews indicated a lack of clarity on managing expired supplies.
Emergency Water Supply Not Maintained Onsite
Penalty
Summary
The facility failed to ensure an onsite emergency water supply was available and maintained in usable condition. During the recertification survey, the surveyor reviewed census documentation showing 168 residents and asked the Food Service Manager where emergency water was stored. The FSM stated the water was not in the building and confirmed it was not stored anywhere onsite. When the Administrator was later asked to show the emergency water supply, the surveyor observed the Administrator ask the FSM for keys to the emergency water supply room, and the FSM retrieved a key. The Administrator stated they did not think emergency water was needed onsite. When the emergency water supply was observed with the Administrator and FSM, the surveyor found cardboard cases of gallon jugs that appeared crushed inward, opened and uncapped jugs, several empty capped jugs, cases with a layer of white powder present, and some water with best-by dates from 2024 and 2025. The supply was estimated at about 250 to 300 gallons, and both the Administrator and FSM confirmed it was not enough for the facility’s residents for three days. The FSM stated the water was not in condition to serve to residents and explained that temperature changes in the storage room had caused gallons of water to explode, with maintenance work recently done in the room. The facility policy stated the Dietary Manager maintains a three-day supply of bottled water at no less than 3 gallons per resident per day, and the disaster and emergency response plan stated the facility has an emergency supply of water located in storage on the lower level.
Insufficient Emergency Water Supply Maintained
Penalty
Summary
The facility failed to ensure a sufficient emergency water supply was available for all 76 residents, as required by its own policy. The policy specified the amount of water needed for drinking, handwashing, cooking, toilet flushing, and miscellaneous uses, based on the number of residents and staff. During observation and interviews, it was found that only a 3-day supply of bottled water for drinking and cooking was maintained by the Dietary Manager. Additionally, in the boiler room, two out of four hot water heaters, each with a capacity of 116 gallons, were not operational, with one having its front panel missing and both turned off. The Business Office Manager confirmed the limited operational capacity, and the Administrator acknowledged that the facility did not have enough water to maintain a 3-day emergency supply for the average number of 52 employees and all residents.
Lack of Written Procedures for Emergency Water Supply
Penalty
Summary
Facility staff failed to develop and maintain written procedures to ensure the availability of water in the event of a loss of the normal water supply. During the survey, it was found that there were no documented processes addressing both drinkable and non-drinkable water needs for the facility. The Administrator verbally reported a plan to provide 64 ounces of water per day for three days for all residents and staff, but this plan was not documented. Observations revealed that the facility's emergency water storage consisted of only 60 gallons, and while there was an agreement with a water delivery company, the documentation from the company did not guarantee supply during high demand and did not address non-drinkable water needs. The surveyor reviewed the facility's emergency preparedness program and found it lacked written policies detailing how water needs would be met during a water outage. The documentation provided by the water delivery company only estimated purified drinking water needs and did not include recommendations for non-drinkable water. During a meeting with facility leadership, the absence of a written process for both drinkable and non-drinkable water provision in the event of a water supply loss was discussed.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to maintain an adequate backup water supply for essential areas in the event of a loss of normal water supply. The facility's policy, as outlined in their Disaster Manual, requires storing one gallon of potable water per day for three days for each resident, plus an additional 50 gallons for staff and volunteers. However, during a facility tour, it was discovered that only 125 gallons of water were available, which is insufficient for the resident census of 85, requiring at least 255 gallons. Additionally, the expiration dates on the stored water containers were not confirmed, and some were found to be expired, raising concerns about the safety of the water for drinking purposes. The Nursing Home Administrator (NHA) mentioned the possibility of using water from the facility's hot water tanks in an emergency. However, a representative from the company that provided the hot water tanks indicated that this water could be contaminated and is not recommended for drinking. The representative highlighted potential risks of bacterial growth and contamination in the hot water tanks. Consequently, the facility was unable to ensure a safe and adequate emergency water supply for residents and staff, as confirmed by the NHA.
Failure to Maintain Adequate Emergency Potable Water Supply
Penalty
Summary
The facility failed to ensure the availability of safe drinking water for all residents in the event of a loss of normal water supply. During interviews, the Administrator acknowledged that there was no policy in place to address water availability during such emergencies, although her expectation was to have enough drinkable water for three days for each resident. Review of the Emergency Preparedness Plan indicated the industry standard is 1.5 gallons of water per person per day, but observation revealed that out of 1,368 gallons of stored water, 1,248 gallons had expired, leaving only 120 gallons of drinkable water available for 132 residents. Further investigation revealed confusion among staff regarding responsibility for monitoring the expiration dates of the potable water supply. The Maintenance Director believed it was the Dietary Manager's responsibility, while the Dietary Manager thought it was the Maintenance Director's duty, despite being responsible for ordering the water. The Corporate Registered Dietician stated that the Dietary Manager was advised to check the water annually and was reminded monthly to monitor expiration dates. However, the lack of a clear policy and defined responsibilities led to the deficiency in maintaining an adequate and safe emergency water supply.
Failure to Rotate Emergency Water Supply
Penalty
Summary
The facility failed to adhere to its established procedures for ensuring water availability in essential areas during a loss of normal water supply. The policy titled "Water Availability," last reviewed on June 13, 2024, mandates that the facility must rotate its emergency water supply regularly. However, during an observation on March 5, 2025, it was found that multiple boxes of emergency water stored on Nursing Unit 1 and in the facility's main kitchen were past their manufacturer's best by dates. Specifically, six out of nine boxes on Nursing Unit 1 and four out of ten boxes in the main kitchen were expired, with dates ranging from July 31, 2024, to September 30, 2024. Interviews with facility staff, including Employee 8 and the Nursing Home Administrator, revealed a lack of clarity and oversight regarding the disposal of expired water. Employee 4, the certified dietary manager, confirmed the presence of additional expired water boxes in the main kitchen storage. The facility did not provide evidence of regular rotation of the emergency water supply, as required by their policy, leading to the deficiency in ensuring water availability during emergencies.
Plan Of Correction
1. Expired was immediately discarded. 2. The Dietary Manager completed an audit of all emergency water to ensure no other water was expired. Dietary Manager ordered more water to replenish expired water. 3. The Dietary Manager educated the dietary department to check emergency water supply and discard of water that is expired and to note to the Dietary Manager to order to replenish. 4. The Dietary Manager or designee will complete weekly random audits for four weeks and then monthly for three months and bring emergency water supply audits to the monthly QA meeting.
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