Noncompliant Use of Portable Space Heater in Staff Office
Summary
A portable space heater was observed on the desk in the Director of Nursing's office during a facility inspection. The space heater's heating element could not be verified as not exceeding 212 degrees Fahrenheit, which is a requirement for use in nonsleeping staff and employee areas according to NFPA 101 19.7.8.1. This observation was confirmed through an interview with the maintenance director at the time of the survey. The presence of the space heater in a health care occupancy area constitutes a failure to comply with regulations prohibiting such devices unless specific safety criteria are met.
Plan Of Correction
K781- Portable Space Heaters Element 1: The Campus removed the portable space heating device from the Director of Nursing office immediately upon identification. Element 2: A one-time audit was completed to ensure there were no other portable space heating devices in office spaces. Element 3: Remedial education was immediately provided to the Interim Director of Health Services regarding portable space heaters, on May 7, 2025. Element 4: DPO/Designee will audit weekly x 3 and monthly x 4 to ensure there are no portable space heating devices in health care occupancies. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.
Penalty
A portable space heater was observed running in the Human Resources Office, in violation of regulations prohibiting such devices in health care occupancies. The facility could not verify that the heater's element did not exceed the allowed temperature, and the maintenance director confirmed the finding.
During a survey, portable space heaters were found in use in residents' rooms, violating the 2012 NFPA101 Life Safety Code. The facility's Administrator stated heaters were provided for comfort, not due to heating issues. The Emergency Preparedness Plan lacked a policy on portable heaters, contributing to the deficiency.
The facility was found to be using portable space heaters in twelve resident sleeping rooms, which is a violation of NFPA 101 standards. This was observed and confirmed during an interview with the maintenance director and the administrator. The use of portable space heaters is prohibited in sleeping areas of health care occupancies.
Portable Space Heater Found in Prohibited Area
Penalty
Summary
A portable space heater was found running in the Human Resources Office during an observation on May 6, 2025. The facility failed to ensure that portable space heating devices were prohibited in all health care occupancies, as required by regulations. Additionally, it could not be verified that the heating element of the space heater did not exceed 212 degrees Fahrenheit, as specified by code. The maintenance director confirmed these findings during an interview at the time of observation. This deficiency could potentially affect 15 occupants in the event of a space heater related fire, as noted in the report.
Plan Of Correction
Element 1 On May 6, 2025, the portable space heater identified in the Human Resources Office was immediately removed from the facility and placed in secure storage pending disposal. A sweep of all administrative, clinical, and non-clinical areas was conducted the same day to identify and remove any other unauthorized space heaters. None were found. The Maintenance Director confirmed removal and documented the action. Element 2 A full facility audit of all office, administrative, breakroom, and storage areas was completed to ensure no other prohibited portable heating devices were present. All residents were evaluated for potential risk exposure. No resident rooms or care areas contained space heaters, and no resident was adversely affected. Element 3 On May 8, 2025, the facility reviewed its Electrical Equipment and Fire Safety Policy. Education was provided to clearly state that all portable space heaters are prohibited, unless explicitly approved in writing by the Administrator and Maintenance Director and confirmed to not exceed 212°F and only used in nonsleeping staff areas. A mandatory in-service training was conducted on May 16, 2025, for all department heads, including Human Resources, Administration, Maintenance, and Nursing, regarding fire safety compliance and the prohibition of portable space heaters under NFPA 101. Element 4 Beginning May 16, 2025, the Director of Maintenance or designee will perform monthly environmental safety rounds, with documentation confirming no prohibited space heaters are in use. Any unauthorized heating devices found will be immediately removed and reported to the Administrator and Safety Committee. Compliance findings will be reviewed monthly during the facility's QAPI meetings for 6 months and quarterly thereafter. The administrator is responsible for the sustained compliance.
Violation of NFPA101 Due to Portable Space Heaters in Resident Rooms
Penalty
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.
Improper Use of Portable Space Heaters in Resident Rooms
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the use of portable space heaters in health care occupancies. During an observation and interview conducted on December 6, 2024, between 12:00 p.m. and 3:00 p.m., it was found that the facility was using portable space heaters to heat twelve resident sleeping rooms, specifically rooms #101-112. This was confirmed in an interview with the maintenance director and the administrator, who acknowledged the use of portable space heaters at the time of the survey. The use of these heaters in sleeping areas is a violation of the requirement that prohibits portable space heating devices in health care occupancies, except in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. On December 6, 2024, the facility removed portable space heaters from all resident rooms. Space heaters on December 6, 2024, were placed at approximately 3pm in nonsleeping staff and employee areas. Also, elements did not exceed the 212 degrees Fahrenheit per regulations. On December 6, 2024, at approximately 10pm the failed air exchanger was replaced with a new unit. Within 30 minutes of the installation, the building established an appropriate temperature range for the entire building.
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