Luxor Nursing and Rehabilitation at Mills Pond
August 4, 2017 Certification Survey

Standard Health Citations

FF10 483.20(b)(2)(i):COMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT

REGULATION: (b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident?s physical or mental condition. (For purposes of this section, ?readmission? means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Recertification Survey the facility did not ensure that the resident's Admission Minimum Data Set (MDS) Assessment was completed within the 14 day time frame after admission. This was evident for one of five residents reviewed for Unnecessary Medications in a total of 27 Stage 2 sampled residents. Specifically, on 8/4/17, review of the Admission MDS for Resident # 190 revealed that the MDS was not completed within the 14 day time frame requirement for completion of Admission MDS assessments. The finding is: Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/4/17 review of the Admission MDS due to be completed by 7/31/17 revealed that it was not completed within the 14 day required time frame. An interview was held with the Registered Nurse (RN) MDS Coordinator on 8/4/17 at 12:15 PM. The RN stated that the MDS should have been completed, but it was missed. 415.11(a)(3)(i)

Plan of Correction: ApprovedAugust 23, 2017

F273 Comprehensive Assessments 14 Days After Admission
-I. Immediate Corrections:-
Resident #190
The Interdisciplinary Team conducted a complete and thorough investigation into the care of the resident #190 due to this deficiency. Based on the investigation findings, the following corrective actions were implemented:
1. The MDS Assessor did not complete the resident?s Admission Minimum Data Set Assessment within the first 14-day time frame, was counseled and re-educated. The counseling focused on the importance of MDS completion within the timeframe requirement.
2. The MDS Coordinator submitted a corrected assessment for this resident on 8/7/17.
II. Identification of Other Residents:-
1. The facility respectfully acknowledges that all new admissions are potentially affected by this deficiency.
2. An audit of all new admissions over the past three months was completed specific to completion of the admission assessment. No other errors were noted.

III. Systemic Changes:
1. The Director of Nursing reviewed the facility?s nursing policy on Comprehensive Assessments for new admissions and noted it to be compliant.
2. The MDS Department will be re-educated regarding completion of the Minimum Data Set Assessments within the structured time frame.
3. A copy of the lesson plan and attendance will be filed for reference and validation.

IV. Quality Assurance Monitoring:
1. The Director of Nursing developed an audit tool to track new admission MDS assessments.
2. This audit will be completed for all new admissions weekly for the first month, monthly for the first quarter and quarterly there after.
3. The MDS Coordinator will present all audit findings to the Quality Assurance Committee for evaluation and follow up.
4. Audits with negative findings will have on site corrective actions implemented by the auditor.
Responsible Party: Director of Nursing/MDS Coordinator

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that for one of five residents reviewed for Unnecessary Medications in a total Stage 2 sample of 27 residents, who was receiving an antipsychotic medication, that a Gradual Dose Reduction (GDR) was attempted during the past year. Specifically, for Resident # 302 with a [DIAGNOSES REDACTED]. The finding is: Resident # 302, an [AGE] year old female with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. No behavioral symptoms were identified on the MDS. The MDS also documented that the resident was receiving an antipsychotic medication daily. The current physician's orders [REDACTED]. The following is the Black Box Warning for the medication [MEDICATION NAME]: Elderly patients with Dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] ([MEDICATION NAME]) is not approved for the treatment of [REDACTED]. The Medical Progress Note dated 10/10/16 documented Dementia with Mood Disorder and weight loss. There were no noted behavioral issues. A Medication Regimen Review (MRR) dated 10/15/16 documented a request for a GDR for [MEDICATION NAME], 0.25 mg at hour of sleep (HS), which was started on 7/18/16. A hand written response on the MRR documented, Psychiatric Consultation. The Medical Progress Note dated 10/18/16 documented mood was stable and without physical or verbal aggression. There were no behavioral issues noted. The Medical Progress Note dated 10/24/16 documented MRR appreciated and addressed; GDR for [MEDICATION NAME]. No behavioral issues were documented on the progress note dated 10/24/16. A Psychiatric Consultation was completed on 10/31/16 and documented a plan to discontinue the [MEDICATION NAME]. The same psychiatric consult documented there were no hallucinations, delusions, or behavioral problems. The Medical Progress note dated and signed 11/3/16 documented that the resident's mood was stable and the resident was without any physical or verbal aggression. The plan was documented as follows: Dementia, [MEDICAL CONDITION]. On [MEDICATION NAME] and [MEDICATION NAME] without reported Adverse Drug Reactions (ADR). Psych meds benefits greater than the risks. Continue with meds. There was no other rationale documented on the Physician's Progress note for not having attempted a GDR. The nursing note dated 12/2/16 at 14:28 documented the following: Resident continues to show fluctuating moods, crying, and anger. Even with much TLC, is difficult to direct. Self propelling on the unit hallucinating, reorienting frequently then resumes a calmer behavior for a time. Spoke with Physician's Assistant to restart, [MEDICATION NAME] 0.5 mg every (q) HS and to see Psych on Monday. There was no documented evidence that a medical work up was completed when hallucinations reappeared prior to the increase of the antipsychotic medication [MEDICATION NAME] in (MONTH) (YEAR). A recent MRR dated 5/13/17 requests a GDR for [MEDICATION NAME] and noted the the dose was increased to 0.50 mg on 12/2/16. The hand written response documented Psych Consult. The Psychiatric Consults completed by a Nurse Practitioner (NP) dated 5/22/17 and 7/24/17 documented in error that a GDR had been attempted and resulted in hallucinations; however, review of the MARs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there was not a GDR attempted. The Licensed Practical Nurse (LPN) was interviewed on 8/4/17 at 9:35 AM. The LPN stated that there had not been a GDR for [MEDICATION NAME] and that in (MONTH) (YEAR) the dosage of the [MEDICATION NAME] was increased. During an interview with the Director of Nursing Services (DNS) on 8/04/2017 at 11:15 AM, she explained that the primary care Physician taking care of the resident in (MONTH) (YEAR) is no longer working in the facility. An interview was conducted with the Psychiatrist Nurse Practitioner (NP) on 8/04/2017 at 11:30 AM. She stated that she had made a recommendation to discontinue [MEDICATION NAME] on the 10/31/16 Consult and that [MEDICATION NAME] had been discontinued for a week and then restarted when behaviors escalated. An interview was conducted with the Charge Licensed Practical Nurse (LPN) on 8/04/2017 at 11:32 AM. The Charge Nurse stated that she cannot explain why the recommended GDR was never attempted. A second interview was held with the Psychiatrist NP on 8/4/17 at 12:00 PM. She explained that she places the Consult report on the nurses desk. She further stated that usually the Physician orders [REDACTED]. In addition, the NP stated that she probably did not speak with the physician because normally they (the primary care physician) do what ever she has asked. She also acknowledged that the [MEDICATION NAME] had not been discontinued (as she had recommended). An interview was held with the Medical Director on 8/04/2017 at 1:30 PM. He stated that the Physician can disagree with the Consultation recommendation to discontinue the antipsychotic medication. He also stated that the Physician's Medical Progress Note dated 11/3/16 was initiated based on the Psych Consult (10/31/16). He further stated that it would have been a benefit if the physician had documented more clarification regarding the benefit outweighing the risk of the [MEDICATION NAME]. Despite the documented plan to discontinue the antipsychotic medication, there was no documented evidence that a GDR had ever been attempted in the past year since 7/18/16. 415.12(l)(1)

Plan of Correction: ApprovedAugust 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329
I. Immediate Correction
Resident #302
The Interdisciplinary Team conducted a complete and thorough investigation into the care of the resident #302 due to this deficiency. Based on the investigation findings the following corrective actions were implemented:

1. Resident # 302 was examined by the psychiatric nurse practitioner and the attending physician regarding the need for a gradual dose reduction for the prescribed [MEDICAL CONDITION] medication. The resident?s medical record and care plan was updated reflecting the initiation of the reduction.
2. An Interdisciplinary Team meeting was held on __8/7/17_______ and resident #302 status was reviewed. The resident?s status will continue to be monitored daily secondary to the reduction for any adverse effects/decompensation. All care plans have been updated.

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 six months. No other residents were effected by this deficiency.
Completion Date:
III. Systemic Changes:
1. The Director of Nursing reviewed the facility?s policy regarding Unnecessary Medications and noted the policy to be in compliance.
2. All Licensed Nursing and Medical Staff will receive re-education by the In-Service Director regarding Unnecessary Medications and the importance of a Gradual Dose Reduction. The lesson plan will concentrate on the following:
? Adequate Indication for Use
? Use of appropriate dose
? Provision of Behavioral Interventions
? Use for appropriate duration
? Adequate Monitoring
? Reduction of dose in the presence of adverse consequences
3. A copy of the lesson plan and attendance will be filed for reference and validation.
IV. Quality Assurance Monitoring:
1. The Director of Nursing developed an audit tool to track resident behaviors, re-evaluation of medication use and gradual dose reductions.
2. Audits will be done on all residents receiving [MEDICAL CONDITION] medications weekly by the ADON for the first month then monthly for three months then quarterly there after.
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 indicated.
Responsible Party: Director of Nursing/Designee
Completion date: 9/29/17

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that each resident's medical record was accurately documented. This was evident for one of five residents reviewed for Unnecessary Medication in a total of 27 Stage 2 sampled residents. Specifically, the Medication Administration Record [REDACTED]. The finding is: Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility Intravenous Therapy Policy dated 4/2016 documented that the Licensed Practical Nurse (LPN) is not permitted to administer Intravenous (IV) medications through a Peripherally Inserted Central Catheter (PICC) line. A Nursing Admission assessment dated [DATE] documented the resident was admitted from the hospital with a [DIAGNOSES REDACTED]. The resident had a PICC line in the right upper extremity and was to be administered the IV antibiotic [MEDICATION NAME] via the PICC line for 19 days. A Physician order [REDACTED]. A Medication Administration Record [REDACTED]. An interview was held on 8/3/17 at 12:30 PM with the LPN who signed the MAR indicated [REDACTED]. The LPN was interviewed again on 8/3/17 at 1:00 PM. The LPN stated that she did not give the IV [MEDICATION NAME], that the RN supervisor administered the medication. An interview was held with the Director of Nursing Services (DNS) on 8/4/17 at 8:15 AM. The DNS stated that the RN Supervisor stated that he administered the medication on 8/2/17. The DNS also stated that the RN should have ensured that the MAR indicated [REDACTED]. The RN who worked on 8/2/17 on the 3:00 PM to 11:00 PM shift was interviewed on 8/4/17 at 11:15 AM. The RN stated that he administered the IV [MEDICATION NAME] on 8/2/17 at 10:00 PM. He did not document that he administered the medication because there was a signature already there. The RN also stated that he should have ensured that the MAR indicated [REDACTED]. 415.22(a)(1-4)

Plan of Correction: ApprovedAugust 23, 2017

F 514: Resident Records Complete/Accurate/Accessible

F514
I. Immediate Corrective Action
Resident #190
The Interdisciplinary Team conducted a complete and thorough investigation into the care of the resident #190 due to this deficiency. The investigation indicated that the resident received all ordered medications via the PICC Line by the RN Supervisor as ordered. Based on the investigation findings, the following corrective actions were implemented:
1. The LPN who signed administration of the intravenous medication on the medication record for resident # 190 was counseled and re-educated. The counseling focused on the importance of intravenous antibiotics administered through a PICC Line, be administered and signed for a by a Registered Nurse. In addition, the re-education included the importance of accurate documentation in a resident?s medical record.
2. The RN Supervisor working on 8/2/17 was counseled and re-educated on the importance of accurate documentation in a resident?s medical record.

II. Identification of Other Residents
1. The facility respectfully states that all residents with a peripherally inserted central venous catheters were potentially affected by this deficiency.
2. An audit of all residents over the past three months having PICC lines was completed. The audit included ensuring all medications administered to residents having a PICC line were administered by a Registered Nurse. No negative findings were noted.
Completion Date:9/29/17
III. Systemic Changes
1. The Director of Nursing reviewed the current policy on peripherally inserted central venous catheters and noted it to meet all regulations.
2. All licensed nursing staff will receive re-education by the In-service Coordinator regarding Central Venous Catheters and the importance of accurate documentation in the medical record.
3. A copy of the lesson plan and attendance will be filed for reference and validation.

Responsible Person: In-Service Coordinator

IV. QA Monitoring
1. The facility developed an audit tool to track all residents having a PICC Line to ensure administration and documentation is completed by a Registered Nurse.
2. Audits will be done daily by the Director of Nursing/Designee.
3. Audits with negative findings will immediate corrective actions for compliance.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated.
Responsible Person: Director of Nursing/Designee

Standard Life Safety Code Citations

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: October 2, 2017

Citation Details

2012 NFPA 99: 11.3.4 Signs 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA 99:11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA 99:11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, the facility failed to ensure that oxygen cylinders stored within the same enclosure were segregated. Additionally, the facility failed to provide the appropriate signage on the door outside the oxygen storage rooms. This occurred on 2 of 3 floors of the facility including the basement. The findings are: On 8/1/2017 and 8/2/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: The oxygen storage room located in the basement of the facility contained storage of E sized oxygen tanks. The tanks were stored in a 6 tank, metal tank holder. It could not be verified at that time, which tanks were full or empty. The door to the oxygen storage room also lacking the appropriate wording required by NFPA 99, 2012 Edition. This same situation was also observed on the 3rd and 2nd floor oxygen storage rooms. In an interview on 8/1/2017 at approximately 11:30am with the Director of Maintenance, he stated it depends on the way the handle of the oxygen tank faces which determines if it's full or empty. He further stated he will address the issue. 2012 NFPA99 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 18, 2017

K-923 Gas Equipment ? Cylinder and Container Storage

I. Immediate Corrective Action
Upon identification of these issues, the facility took immediate corrective action. Additional holders were immediately procured for all Oxygen Rooms. This allowed us to differentiate between full and empty tanks. Appropriate signage was affixed to denote this. In addition, the correct door signage was procured and put on the doors in conformance with NFPA 99, 2012 edition.

II. Identification of other Residents
Since this issue pertained to various oxygen storage rooms within the building, all residents were potentially affected by this deficient practice.
III. Systematic Changes
As described immediate corrections were undertaken. All areas are checked daily to assure proper holders, storage and appropriate signage on the door. Any corrections, if indicated are immediately addressed.
IV. Q.A. Monitoring
Daily preventive maintenance checks are done on all oxygen storage areas. The Director of Environmental Services will report to the Quarterly Q.A. Committee the results of these audits for a one year period to ensure ongoing compliance.
V. Responsible Party
The Director of Environmental Services/Designee is responsible for continued compliance with all oxygen related handling.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: October 2, 2017

Citation Details

2010 NFPA 13: 8.15.3.2.1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within Stair B were not provided with automatic sprinkler coverage. This was noted in one of two exit stairwells. The findings are: On 8/1/17 at approximately 10:00am during the recertification survey, Stair B was not provided with automatic sprinkler coverage. Specifically, sprinklers were lacking at the interior landing of the stairwell going to the basement level. The stairwell was separated by a fire rated door between the 1st floor exit stair landing and the basement. In an interview on 8/1/17 at approximately 11:15am, the Director of Maintenance stated he would call the company to come in to add a sprinkler. 2010 NFPA 13 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 18, 2017

K-351 Sprinkler System
I. Immediate Corrective Action
Upon identification of this issue, a plumbing sprinkler company was immediately contacted and the appropriate sprinkler heads where installed in the identified areas. Work was completed (MONTH) 1, (YEAR) by 8:00 PM in the evening.

II. Identification of other Residents
As this deficiency impacted the sprinkler system, all residents are potentially affected.
III. Systematic Changes
As mentioned, sprinkler heads were added to the affected areas. All sprinkler heads are monitored and checked in accordance with regulatory standards on an ongoing basis.
IV. Quality Assurance Monitoring
The sprinkler system is monitored on a semi-annual basis for any needs, repairs. Any observations are promptly reported to Administration for appropriate follow-up , if indicated. Environmental Services Director will report to the Q.A. committee his findings for a one year period.
V. Responsible Party
The Director of Environmental Services/Designee is responsible to monitor the sprinkler system on an ongoing basis.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: October 2, 2017

Citation Details

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. 2012 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. 2012 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted for 3 of 3 floors in the facility, including the basement. The findings are: On 8/1/2017 and 8/2/2017 between 9am and 3pm during the recertification survey, fire-rated doors were not provided with legible fire-rated labels. Locations include, but are not limited to: 1) 3rd Floor, Smoke Barrier Door 2) 2nd Floor, Smoke Barrier Door 3) 1st Floor, Smoke Barrier Door 4) Basement, Stair B Exit Door In an interview on 8/1/2017 at approximately 9:55am with the Director of Maintenance, he will try to remove the paint on the door label. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2

Plan of Correction: ApprovedSeptember 18, 2017

K-374 Smoke Barriers
I. Immediate Corrective Action
The Director of Environmental Services assessed the area identified and determined that the work to be done was within the staff?s capabilities to correct.

II. Identification of other Residents
The Director of Environmental Services has identified all areas that may potentially affect the safety of the residents and staff. All doors were inspected for legible fire-rated labels.
III. Systemic Changes
The following systemic changes were performed to ensure compliance with K374. The paint was removed from all fire-rated labels. The fire-rated labels were inspected on all doors and are legible.
IV. Quality Assurance Monitoring
The Director of Environmental Services will ensure that all fire-rated labels are legible and in good repair on all doors. The Director of Environmental Services has developed an audit tool to inspect the fire-rated label on all doors. 100% of all fire-rated doors will be inspected for legible fire-rated labels monthly for the first three months then 100% quarterly thereafter.
V. Responsible Party
The Director of Environmental Services/Designee.