NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101 9. 6. 1. 6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A complaint investigation survey, ACTS reference #NY 662 was conducted at King Street Home Inc. on (MONTH) 29, 2025, to determine compliance with 42 CFR Part 483 requirements of Long-Term Care Facilities. Based on document review and staff interviews during the standard survey, the facility did not ensure that measures were put in place to provide for occupant safety during an impairment of the fire alarm system [MEDICATION NAME] greater than 4 hours as per 2012 NFPA 101. Specifically, the facility did not notify the Department of Health and did not conduct a fire watch while the fire alarm was impaired. The findings include: On (MONTH) 29, 2025, from 9 am - 1 pm, on a tour of the facility, it was noted that the West Unit was being renovated and there was signage at the Nursing stations indicating Fire Alarm Out of Service, in Case of Fire Call 911. On the same day at approximately 10 am, the Director of Maintenance stated that the fire alarm system was being placed offline to prevent the alarm from triggering from the dust and the work had been ongoing for approximately two weeks. The Director of Maintenance further stated that going forward, DOH would be notified if the fire alarm is impaired for longer than 4 hours and a Fire Watch would be implemented if the Fire Alarm is impaired for any amount of time. At the exit conference on (MONTH) 29, 2025, at approximately 1:00 PM, the Assistant Administrator stated that the facility would implement the fire watch on an hourly basis going forward. 2012 NFPA 101: 9. 6. 1. 6 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility will notify the department of health and will conduct a fire watch when/if the fire alarm is impaired for more than 4 hours at any given time.03/01/2025 2. The facilitys Fire Safety and Alarm Impairment Policy has been revised to ensure full compliance with NFPA 101: 9. 6. 1. 6 and NYCRR regulations. Updates include: Mandatory notification to the Department of Health for any fire alarm impairment [MEDICATION NAME] over 4 hours. Immediate implementation of a fire watch whenever the fire alarm system is offline, regardless of the duration. Documentation of fire watch rounds, including times and assigned staff, to be maintained for regulatory review. All involved staff members have been in-serviced. 03/01/25 3. The Maintenance Director will conduct weekly audits for the next 90 days to verify compliance with fire alarm impairment protocols and fire watch implementation. Any non-compliance will be immediately addressed. 03/01/25 4. Maintenance Director will be responsible for making Environmental rounds quarterly and reporting findings to Assistant Administrator to review at QA to ensure compliance for one year. 03/01/25 5. Responsible party: Director of Maintenance and Assistant Administrator 03/01/25 |