Lack of Written Procedures for Emergency Water Supply
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.
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the surveyor observed crushed cases, opened and uncapped jugs, empty jugs, white powder on some cases, and water with outdated best-by dates.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.
Insufficient emergency drinking water supply: The facility did not maintain the amount of drinkable water required by its emergency plan. Surveyors found only 257 gallons stored in water jugs across two storage areas, while the plan required 915 gallons for residents and staff. The Maintenance Director confirmed the storage areas did not meet the planned capacity, and additional water in water heaters, toilet tanks, and boiler room storage tanks was not acceptable for drinking water.
Insufficient Emergency Water Supply: Surveyors found that the facility’s only emergency water supply was 23 gallons of bottled water and one 5-gallon jug stored in the kitchen pantry for a census of 61 residents. The DM stated she was not aware of any additional water on site and did not think the facility had enough to supply all residents during a water emergency. The ADM confirmed the pantry water was the only emergency supply in the building and was not enough to continue daily operations if a water outage occurred; she also stated prior emergency water had expired and had not yet been restocked.
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.
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.
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 drinking water supply
Penalty
Summary
The facility failed to follow its established emergency water storage procedures to ensure water would be available to essential areas during a loss of normal water supply. The facility policy, Emergency Preparedness and Planning dated 11/1/25, stated the emergency water supply recommendation from the Red Cross and FEMA was one gallon per person per day. The Emergency Water Supply plan identified a total bed capacity of 200 residents and 105 staff, for 305 total people, and calculated that 915 gallons would be needed for three days. During a tour with the Maintenance Director, the Long-Term Care Supply Room contained 16 boxes of one-gallon water containers, totaling 96 gallons, and the estimated storage volume for that area was 100 gallons. The Arcadia storage area contained 36 one-gallon jugs on top shelves and five-gallon jugs on lower shelves, totaling 161 gallons, with an estimated storage volume of 200 gallons. The Maintenance Director confirmed the facility did not meet the adequate volume for either storage area as outlined in the plan and stated additional water was present in boiler room water heaters, toilet tanks, and storage tanks; however, those sources were not acceptable for drinking water. The Nursing Home Administrator later confirmed the facility did not have the required amount of drinkable emergency water on hand for residents and staff.
Insufficient Emergency Water Supply
Penalty
Summary
The facility failed to establish procedures to ensure that enough water was available in the event of a loss of normal water supply. During observation of the kitchen, surveyors found four packs of 35 bottled waters at 16.9 fl oz each and one 5-gallon jug stored in the kitchen pantry as the facility’s emergency water supply. The DM stated this was all of the emergency water available in the building and said she was not aware of any additional water stored elsewhere. She also stated she was unsure how much water was needed per resident and did not think the facility currently had enough to supply all residents during a water emergency. The ADM stated the facility received water from a supplier and that orders for the required water supply would be placed soon. She confirmed that the water in the kitchen pantry was the only emergency supply in the building and that it was not enough to continue daily operations if a water emergency occurred. She also stated that emergency supply water had previously been discarded because it expired and had not yet been restocked. Review of the facility’s emergency preparedness guidance stated that at least one gallon of bottled water per person per day for 3 days should be maintained on hand, including residents, staff, families of residents, and families of staff who would be at the facility.
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.
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.
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