Luxor Nursing and Rehabilitation at Mills Pond
February 15, 2019 Certification Survey

Standard Health Citations

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: March 31, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary medications. This was evident for for two of eight residents reviewed for [MEDICAL CONDITION] medication use. Specifically, 1) Resident # 186 received a [MEDICAL CONDITION] medication Quetiapine ([MEDICATION NAME]), an antipsychotic medication, without documented evidence of a clinical indication or medical assessment for the use of Quetiapine; and 2) Resident # 152 received an antipsychotic medication for an excessive duration without an attempt at a Gradual Dose Reduction (GDR) and in the absence of clinical symptoms. The findings are: 1) Resident #186 is [AGE] years old and was admitted to the facility for short term rehabilitation on 1/10/19 with diagnosed including: [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition. The MDS documented the resident had no symptoms of [MEDICAL CONDITION], Hallucinations or Delusions. The MDS also documented the resident received 7 days of antipsychotic medication during the look back period. A Medical Diagnoses Record dated 1/10/19 documented Dementia, Muscle weakness and Hypertension. The Medical Diagnoses Record was updated on 1/23/19 and documented a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Pharmacy review dated 1/10/19 documented that Quetiapine is not approved by the Food and Drug Administration (FDA) to treat Dementia, and there was a black box warning for geriatric residents that may increase the mortality rate. The pharmacy review documented there is no [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Psychiatric evaluation dated 1/14/19 documented that the resident was [AGE] years old with Dementia and was admitted on [DATE]. The Psychiatric evaluation documented no reports of mood lability and that the resident's insight and judgement were impaired. The Psychiatric evaluation documented that a GDR was not completed due to possible decompensation of the resident's behavior and to continue the current medications. The Psychiatric evaluation also documented that the Physician agreed with the evaluation. physician progress notes [REDACTED]. All of these physician progress notes [REDACTED]. There is no documented evidence of an assessment or medical indication for the continued use of Quetiapine. Behavior Notes dated 1/20/19, 1/28/19, 2/4/19, and 2/11/19 had no documented evidence of [MEDICAL CONDITION], Hallucinations or Delusions. The physician's orders [REDACTED]. Observations on 2/8/19 at 8:05 AM and 1:15 PM revealed the resident was sleeping in her bed. An interview was held with the resident's Certified Nursing Assistant (CNA) on 2/13/19 at 8:24 AM. The CNA stated the resident is calm, cooperative, never exhibits any behaviors. The resident answers questions, can inform you of what she needs, wheels herself around in the wheelchair and attends activities. An interview was held with the Licensed Practical Nurse (LPN) on 2/14/19 at 10:00 AM. The LPN stated the resident is pleasant and cooperative, exhibits no [MEDICAL CONDITION] or behavior concerns. An interview was held with the Psychiatric Nurse Practitioner (NP) on 2/14/19 at 10:12 AM. The NP stated that Resident #186's son reported the resident lived alone prior to admission and reported the resident stated to him she was hallucinating, reporting that she thought someone might break into her home. The NP stated that is why she did not decrease the Quetiapine. The NP stated the [DIAGNOSES REDACTED]. An interview was held with the Pharmacy consultant on 2/14/19 at 1:10 PM. The Pharmacist stated that the resident should not be receiving Quetiapine with a [DIAGNOSES REDACTED]. An interview was held with the Registered Nurse (RN) Assistant Director of Nursing (ADON) on 2/15/19 at 8:00 AM. The ADON stated that when the resident was admitted to the facility the Physician was informed of the admission medications and determines the need and diagnoses for all the admission medications. An interview was held with the Director of Nursing Services (DNS) on 2/15/19 at 8:32 AM. The DNS stated that the resident should not be on Quetiapine and that the Physician should have addressed the [MEDICAL CONDITION] medication Quetiapine. An interview was held with the Physician on 2/15/19 at 8:45 AM. The Physician stated that he did not document on the use of Quetiapine for Resident #186. The Physician stated that residents with Dementia sometimes have [MEDICAL CONDITION] but that during his visits with the resident she was calm, pleasant and did not show any signs of [MEDICAL CONDITION]. The Physician stated that he was not aware that Dementia related [MEDICAL CONDITION] is not an indication for the use of the [MEDICAL CONDITION] medication Quetiapine.
2) Resident # 52 is [AGE] years old and was admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had modified independence in cognitive skills for daily decision making. The resident's Mood Score was 13, indicating the resident has moderate depressive symptoms. The MDS documented the resident was receiving Antipsychotic and Antidepressant medications daily and that Antipsychotic medication was administered on a routine basis without an attempt of a GDR. The physician's orders [REDACTED]. The original order, documented in the electronic medical record, was dated 8/31/13. A Comprehensive Care Plan (CCP) titled, The Potential to Demonstrate Physical Behaviors, initiated 8/9/16, was updated on 12/27/18 and documented the resident has [MEDICAL CONDITION] and may think the food is poisoned. There were no updates to the CCP documenting these behaviors being exhibited by the resident. The [MEDICAL CONDITION] Medication Care Plan CCP, initiated on 1/2/13 and updated on 12/27/18 documented that no GDR will be attempted as per history or past decompensation. A Psychiatric Consultation dated 3/5/18 documented the resident had diagnoses of Dementia, [MEDICAL CONDITION] and Depression and that [MEDICATION NAME] was to be continued. The consultation documented that the dose reduction in the past had resulted in decompensation, weight loss, and delusions. There was no significant weight loss as documented on the most recent MDS dated [DATE]. Subsequent Psychiatric Evaluations dated 6/11/18, 9/10/18 and 12/10/18 all documented that the resident was not a candidate for a GDR of [MEDICATION NAME] related to long history of Paranoia and Delusional thinking. A Pharmacist Consultation note dated 9/29/18 recommended to consider if a GDR could be attempted. The response documented from the Physician was that GDR was contraindicated secondary to targeted symptoms worsened. Behavior Monitoring Weekly reports dated of 5/2/18, 5/16/18, 5/23/18, 6/6/18, and 6/20/18 documented that there had been no change in the resident's behavior from baseline. Behavior Monitoring notes dated 11/14/18, 11/21/18, 12/5/18, 12/12/18, 12/19/18, 12/24/18 and weekly through 2/11/19 documented no behaviors and no behavioral interventions were required by staff. The Pharmacy Consultant documented a recommendation for a GDR on 1/26/19. The response from the Physician was that the recommendation was reviewed with the Psychiatric Nurse Practitioner/NP, who had prescribed the [MEDICATION NAME], and a GDR would be contraindicated secondary to worsening behavior. The resident was observed sleeping in bed on 2/08/19 at 12:01 PM, with her head covered with a towel. The Registered Nurse (RN)/Unit Manager was interviewed on 2/15/19 at 9:31 AM. The RN stated that there have been no recent episodes of agitation or aggression and that she had never heard the resident exhibit any paranoia. The RN stated that the resident feeds herself with supervision, without any paranoid verbalizations noted by the RN. A subsequent observation of the resident was made on 2/15/19 at 9:32 AM. The resident was observed sleeping in bed. The resident's CNA was interviewed on 2/15/19 at 9:56 AM. The CNA stated that she has cared for the resident since the resident's admission. The CNA stated that the resident has never been aggressive, often prefers to stay in the bed and can be resistive to getting out of bed. The CNA stated that the resident has some odd behaviors but they are not dangerous to the resident or to others. The CNA further stated that the resident will attend some short term activities. The CNA described the resident as generally pleasant and quiet, who will eat in the dining room most times, does not voice any complaints and prefers to stay in her room. The resident's Attending Physician/MD was interviewed on 2/15/19 at 11:04 AM. The MD stated that a GDR was not attempted because the resident has had significant behaviors in the past. The Psychiatric Nurse Practitioner/ NP was interviewed on 2/15/19 at 12:27 PM. The NP stated that [MEDICATION NAME] was the only medication that was successful for the resident. The NP stated that prior attempts at a GDR were unsuccessful per the resident's history and that the resident had decompensated and the behaviors had returned. 415.12(l)(2)(i)(ii)

Plan of Correction: ApprovedMarch 4, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action:

The Interdisciplinary Team conducted a complete and thorough investigation into the care of residents #186 and #152 relative to this deficiency. Based on the investigation findings the following corrective actions were implemented:
1. Residents #186 and #152 were examined by the psychiatric nurse practitioner and attending physicians regarding the need for continued use of a [MEDICAL CONDITION] medication in the absence of a medical indication and in the absence of a gradual dose reduction. Gradual dose reductions were initiated for both residents. The residents' medical records and care plans were updated reflecting the initiation of the reductions.
2. An Interdisciplinary Team Meeting was held on 2/18/19 and both residents statuses were reviewed. Resident #186 was re-integrated into the community as planned on 2/18/19. Resident #152 status will continue to be monitored daily secondary to the reduction for any adverse effects/decompensation. All care plans have been updated.
Completion date: 2/18/19
II. Identification of Other Residents:
1. The facility respectfully acknowledges that all residents receiving [MEDICAL CONDITION] medications can be potentially affected by this deficiency.
2. An audit of all residents receiving [MEDICAL CONDITION] medications was completed to ensure a Gradual Dose Reduction was initiated within the last 6 months, and that there is a medical indication for the continued use of the [MEDICAL CONDITION] medications. No other residents were effected by this deficiency.
Completion Date: 3/8/19
Responsible party: Director of Nursing
III. Systemic Changes:
1. The Director of Nursing reviewed the facility's policy regarding Unnecessary [MEDICAL CONDITION] Medications and noted it to be compliant.
2. Although the facility's policy was complaint relative to the use of Unnecessary [MEDICAL CONDITION] Medications, all licensed nurses and medical staff will receive re-education by the Director of Nursing. The lesson plan will concentrate on the following:
- Residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition and documented in the clinical record.
- Residents do not receive [MEDICAL CONDITION] medications pursuant to a prn order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.

- Residents receiving [MEDICAL CONDITION] medications receive a Gradual Dose Reduction at least every 6 months.
- Provision of behavioral interventions and the importance of Black Box warnings
Completion date: 3/15/19
Responsible party: Director of Nursing
IV. Quality Assurance Monitoring:

1. The Director of Nursing developed an audit tool to track residents receiving [MEDICAL CONDITION] medications, including review of medical indications and gradual dose reductions documented in the clinical record.

2. Audits will be done on all residents receiving [MEDICAL CONDITION] medications weekly by the DNS for the first month, then monthly for three months, then quarterly for the following two quarters.

3. Audits with negative findings will have on site corrective actions implemented by the auditor.
4. Audit findings will be presented to the Quality Assurance Committee quarterly for evaluation and follow up as needed.
Responsible party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 5, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the did not ensure that an extension cord was not used as a substitute for fixed wiring, and that the approved relocatable power strip was utilized in a patient care area. This was noted on 1 of 3 resident floors. The findings are: During the Life Safety Code survey conducted on 02/13/19 at approximately 10:25am, the following was noted in the Neurology Examination Room on the first floor: 1. An extension cord was noted used for connecting work computers. 2. A Non-compliant relocatable power strip was noted within the room. In an interview at this time, the Director of Maintenance stated that the extension cord would be removed and that a code compliant relocatable power strip would be provided in the examination room for patient care related devices. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 10NYCRR 711.2(a)(1) 10 NYCRR 415.29 2012NFPA101: NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedMarch 20, 2019

1) The identified power strip and extension cord was removed immediately.
2) A full house audit has been completed to identify any additional un approved power strips and/or extension cords being used within the facility. Any unapproved power strips and extensions discovered were removed immediately. No residents have been affected. All residents had potential to be affected.
3) The Environmental Services Director was educated regarding the dangers of using unapproved power strips and extensions in the facility.
4) The Environmental Services Director/Designee will conduct audit of power strips and extension cords used in the facility weekly for the first month and monthly for the next 6 months to ensure compliance.
The Environmental Services Director will report all findings to the QA committee on a monthly basis. The committee will monitor progress to ensure compliance with regulatory standards.
5) Responsible Party: Environmental Services Director

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 5, 2019

Citation Details

2012 NFPA 101: 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: Standard for the Installation of Sprinkler Systems. 8.6.3.4 Minimum Distances Between Sprinklers. 8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, it was noted that sprinklers were spaced less that 6ft on center on 2 of 3 resident floors. The findings are: During the Life Safety Code survey conducted on 02/13/19 between 9:30am and 12:00pm, sprinkler heads were noted spaced less than 6 ft on center. Examples included the following: - 3 South Unit of the 3rd floor: two sprinklers spaced approximately 4ft apart within the nursing station and two spaced approximately 1ft apart in the corridor outside of the Dayroom. - 2 North Unit of the 2nd floor: two sprinklers spaced approximately 5'.2 apart within the common shower room In an interview on the same day approximately 10:00am, the Director of Maintenance stated that the identified issues with the sprinkler spacing would be addressed. 2012 NFPA 101: 9.7 2010 NFPA 13: 8.6.3.4 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedMarch 20, 2019

1) The facility contacted Apollo Fire Sprinkler Company, the service company for the sprinkler system, to address the proximity of the sprinkler heads. The Environmental Services Director has been educated by the administrator on the requirements ensuring that sprinkler heads are properly situated to ensure regulatory compliance.
2) An audit of all sprinkler heads within the facility has been conducted to ensure compliance of sprinkler head locations and proximity throughout the property. No residents have been affected. All residents had potential to be affected.
3) The Environmental Services Director was educated by the administrator on the requirements ensuring that sprinkler heads are properly situated to ensure regulatory compliance.
4) The Environmental Services Director/Designee will conduct weekly audits of sprinkler heads for the first 30 days and monthly for the next 6 months to ensure proper proximity and placement of sprinkler heads.
The Environmental Services Director will report all findings to the QA committee on a monthly basis. The committee will monitor progress to ensure compliance with regulatory standards
5) Responsible Party: Environmental Services Director

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 5, 2019

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.2* Inspection. 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, sprinkler heads showed signs of visible corrosion in the main kitchen, and sprinkler heads were noted with foreign material in the laundry department. This was noted in the basement. The findings are: During the Life Safety Code survey conducted on 02/13/19 between 9:30am and 12:00pm, the following was noted in the basement: 1. Sprinkler heads showed signs of corrosion or discoloration in the main kitchen. Examples included three sprinklers in the dishwashing location, and two within the mop- room. 2. Three sprinkler heads were noted coated with lint/dust in the laundry drying room. In an interview on the same day at approximately 11:00am, the Director of Maintenance stated that the sprinkler company would be contacted to address the concerns with the sprinkler heads and further stated that the lint material would be cleaned off from the sprinkler heads in the laundry department. 2012 NFPA 101: 9.7.5, 2011 NFPA 25: 5.2, 5.2.1.1.2, 5.2.1.1.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 20, 2019

1) The facility contacted Apollo Fire Sprinkler Company, the service company for the sprinkler system to ensure sprinklers exhibiting signs of corrosion are replaced. The Environmental Services Director has been educated by the administrator on the requirements regarding Sprinkler heads to ensure proper functioning of emergency fire sprinkler heads at all times.
2) All other areas of the facility sprinkler system have been inspected for signs of corrosion, discoloration and/or foreign particles such as paint, lint or dust and have been found to be in compliance. No residents have been affected. All residents had potential to be affected.
3) The Environmental Services Director was educated by the administrator on the requirements regarding Sprinkler heads to ensure proper functioning of emergency fire sprinkler heads at all times.
4) The Environmental Services Director/Designee will conduct audits of sprinkler heads weekly for one month and monthly for 6 months ensuring required regulatory standards are met. The Environmental Services Director will report all findings to the QA committee on a monthly basis. The committee will monitor progress to ensure compliance with regulatory standards.
5) Responsible Party: Environmental Services Director

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2019
Corrected date: April 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. This requirement is not met as evidenced by: Based on observation and staff interview, smoke barrier door assemblies were not provided with legible labels indicating a fire rating of at least 20 minutes on 3 of 3 floors. Additionally, the emergency exit stairwell doors lacked legible fire resistance rated labels on 2 of 3 floors inspected for compliance. This is a repeat deficiency. The findings are: On 2/13/2019 between 9:25am and 2pm during the recertification survey, the following was observed: 1. Fire doors located in dividing sections of the facility's wing on each floor did not have fire labels show a fire rating of at least 20 minutes. Examples include: 3rd floor near North Wing 2nd floor South wing near room [ROOM NUMBER] 1st floor South wing near room [ROOM NUMBER]/118 2. Emergency exit stairwell doors lacked legible fire rated labels. Examples included the stairwell doors to stair1 and 3 of the 2nd floor. In the exit interview conducted on 2/14/2019 at approximately 2pm, the Director of Maintenance stated the identified doors would either be replaced or recertified to make sure they have the appropriate labels. A Record review of the Plan of Correction, for the K374 deficiency cited during the 08/04/17 recertification survey regarding the ineligible fire rated labels on the smoke barrier doors revealed that the paint was removed from all fire-rated labels. The fire-rated labels were inspected on all doors and are legible with a completion date of 10/02/17. As stated above, the smoke barrier doors did not have legible fire rated labels. 2012 NFPA 101: 19.3.7.6, 19.3.7.8, 19.3.7.9 10 NYCRR 415.29 NYCRR 711.2(a)

Plan of Correction: ApprovedMarch 20, 2019

1) The facility contacted Intertek, the service company for the smoke barrier doors fire rating, to address those doors with ineligible fire resistance labels. All such doors will be tested for compliance and will receive proper labeling. The Environmental Services Director has been educated by the administrator on the requirements ensuring that smoke door resistance ratings are properly labeled to ensure regulatory compliance.
2) A full facility wide audit has been conducted to identify any doors lacking proper fire rated labeling. No residents have been affected. All residents had potential to be affected.
3) The Environmental Services Director was educated by the administrator on the requirements ensuring that smoke door resistance ratings are properly labeled to ensure regulatory compliance.
4) The Environmental Services Director/Designee will conduct an audit of fire door labels weekly for the first month and monthly for the next 6 months to ensure proper fire resistance labeling.
The Environmental Services Director will report all findings to the QA committee on a monthly basis. The committee will monitor progress to ensure compliance with regulatory standards.
5) Responsible Party: Environmental Services Director