Deficiency in Emergency Water Supply Maintenance
Summary
The facility failed to maintain the required emergency water supply for its residents in the event of a loss of normal water supply. During a survey, it was observed that the facility, which was licensed for 120 beds and had a census of 86 residents, only had 22 cases of water, each containing six one-gallon bottles, totaling 132 gallons. This was insufficient to meet the requirement of one gallon per person per day for three days, which would require 258 gallons. The Food Service Director (FSD) initially miscounted the number of cases, stating there were 22 cases when there were actually 36 cases, totaling 216 gallons. Additional water was ordered during the survey, but the initial deficiency was acknowledged by the Licensed Nursing Home Administrator (LNHA). The facility's policies and contracts indicated that a three-day supply of water should be maintained, with specific guidelines for emergency situations. However, the facility did not have the required amount of water on hand initially, and there was confusion regarding the responsibility for ordering and maintaining the emergency water supply. The Director of Maintenance (DM) stated that he did not order the water and that it was the FSD's responsibility. The facility's contract with a food service vendor also outlined the need for maintaining an inventory of bottled water, but the facility did not meet these requirements at the time of the survey.
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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