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.