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K0781
E

Violation of NFPA101 Due to Portable Space Heaters in Resident Rooms

Brentwood, New York Survey Completed on 01-17-2025

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 was found to be in violation of the 2012 NFPA101 Life Safety Code during an Abbreviated Survey (Complaint NY 340) due to the use of portable space heaters in residents' sleeping rooms. The survey, conducted on January 16, 2025, revealed that portable space heaters were in use in five residents' rooms across two nursing units, despite the code's stipulation that such devices are prohibited in all health care occupancies unless used only in nonsleeping staff and employee areas and the heating elements do not exceed 212°F (100°C). The temperatures in these rooms varied, with some rooms experiencing drafts and others having heating units covered or turned off. The facility's Administrator acknowledged that portable space heaters were provided to residents upon request for comfort, not due to any issues with the heating system. However, the facility's Emergency Preparedness Plan and Equipment Management policy did not address the use of portable space heaters, indicating a lack of compliance with the required safety standards. The absence of a specific policy for portable space heaters contributed to the deficiency, as the facility failed to ensure adherence to the NFPA 101 Life Safety Code requirements.

Plan Of Correction

Plan of Correction: Approved February 20, 2025 i. Heaters were immediately removed from all the resident rooms, all resident rooms checked for heaters and none were found. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and included 2012 NFPA101 19.7.8 Portable Space-Heating Devices regulation, maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and there are no portable space heaters in resident areas. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for K781 tag.

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