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E0015
F

Failure to Establish and Maintain Emergency Subsistence Policies and Procedures

Stephenson, Michigan Survey Completed on 06-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during emergencies, as required by federal regulations. During an interview, the Dietary Manager was unable to confirm the existence of a three-day emergency menu and stated that food provisions would be based on the regular menu cycle. The Dietary Manager also expressed uncertainty about how the facility would manage food service if dietary staff were unable to work due to weather conditions. It was noted that a three-day emergency menu had previously existed but was not re-established after a change in food vendors. Additionally, a review of the facility's emergency preparedness plan revealed inconsistencies regarding water supply arrangements. The written policy indicated reliance on one vendor for emergency water provision, while the Administrator reported having a contract with a different vendor not reflected in the plan. These deficiencies indicate a lack of clear, updated, and actionable procedures to ensure the availability of food, water, and other essential resources for staff and patients in the event of an emergency.

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