Failure to Maintain Adequate Emergency Water Supply
Summary
The facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. During a survey, it was observed that the facility, which had a census of 123 residents, only had 132 gallons of emergency water available, whereas the requirement was 369 gallons (1 gallon per resident per day for 3 days). The Food Service Director (FSD) acknowledged the deficiency and mentioned that some water had been discarded due to expiration, and an order had been placed to replenish the supply. However, the provided invoices did not show that water had been ordered prior to the surveyor's inquiry. The Licensed Nursing Home Administrator (LNHA) and the FSD confirmed that the facility's policy required maintaining a 3-day emergency water supply based on the current census. The LNHA stated that the responsibility for ensuring the emergency supply was sufficient lay with the FSD, and there was no delay in approval or delivery of the order. Despite this, the surveyor found that the facility did not have the required amount of emergency water at the time of the survey, and the FSD admitted that the emergency water supply was insufficient based on the resident census.
Penalty
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The facility failed to maintain an adequate emergency water supply, potentially affecting all 74 residents. The emergency water policy lacked details on storage and distribution, and the current supply was insufficient. During an observation, staff struggled to locate the emergency water, which was found to be only 93 gallons, far below the estimated need for three days or a week.
The facility did not follow its procedure to maintain an adequate emergency water supply on site, potentially affecting all 61 residents. The emergency water supply was kept off site, contrary to the facility's policy, which required storing three days' worth of water in the old assembly hall supply closet.
The facility did not ensure an adequate emergency water supply, potentially affecting all 65 residents. The Administrator provided a document from the food service supplier indicating that in an emergency, the supplier might not be able to provide the necessary water. The facility had not arranged for an alternate water vendor.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was maintained, which had the potential to affect all 74 residents. The emergency water supply policy lacked provisions for storing potable and non-potable water, methods for distributing water, and details on estimating the needed volume of water. During an interview, the Administrator indicated that the emergency water plan was in the survey readiness binder, which included steps for short-term water shut-offs. However, the contract with the emergency water supplier, WC #1050, stated that water would be provided within 24 to 48 hours, with exceptions if the supplier was also affected by the outage or if fulfilling the contract would endanger their personnel or violate regulations. An observation with the Kitchen Manager revealed that emergency water was not stored in the kitchen, and staff had difficulty locating it. After a search, 93 gallons of water were found in a supply closet, which was less than the 150 gallons typically stored. The Kitchen Manager admitted that the supply was insufficient and could not provide evidence of a recent order for more water. The facility's policy estimated water needs for three days to be between 169.65 to 286.95 gallons, and for a week, between 395.85 to 669.55 gallons, indicating a significant shortfall in the current supply.
Failure to Maintain On-Site Emergency Water Supply
Penalty
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.
Failure to Ensure Emergency Water Supply
Penalty
Summary
The facility failed to ensure provisions were made to have water available in the event of an emergency, potentially affecting all 65 residents. During the entrance conference, the Administrator was asked about the facility's emergency water provisions. A document from the facility's food service supplier, dated 11/01/23, was provided, indicating that in an emergency, the supplier might not be able to provide the recommended amount of water. The document recommended that the facility ensure they had an alternate vendor set up. On 06/18/24, the Administrator confirmed that the facility had not made alternate arrangements for water provision in emergencies.
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