Pennsylvania Department of Health
AVENTURA AT TERRACE VIEW
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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AVENTURA AT TERRACE VIEW - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on February 21, 2024, at Aventura at Terrace View, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #134902
Component 01
Main Building (A, B & C wings)

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Aventura at Terrace View was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, the facility failed to ensure that exit access corridors were maintained on one of three floors.

Findings include:

Observation on February 21, 2024, at 10:30 a.m., revealed three stationary chairs were stored in the corridor near room C-255 on the secnd floor.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the chairs were being stored in the corridor.

Plan of Correction - To be completed: 04/15/2024

Upon identification chairs were removed.
A facility wide check of resident chairs was completed by maintenance department was completed to ensure chairs were not blocking hallways/egress.
during daily ambassador rounds hallway clutter will be added.
All staff will be educated, by director of maintenance/designee on the issues of having unsecured furniture in hall ways.
Resident and family will be educated as well regarding pulling chairs in the hall way, in addition more seating will be placed in resident lounges.
ambassador rounds will be discussed at daily morning report and at QAPI meeting.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to maintain egress on two of three floors.

Findings include:

Observation on February 21, 2024, between 10:05 a.m. and 11:22 a.m., revealed the following:

a. 10:05 a.m., second floor, nurse restroom at nurse station was installed with deadbolt lock.
b. 11:20 a.m., first floor, exit door at the stair tower, located near room B-126, required excessive force to open.
c. At 11:22 a.m., first floor, nurs restroom at the nurse station was installed with deadbolt lock.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the egress doors defiencies.

Plan of Correction - To be completed: 04/15/2024

The identified doors with deadbolts were immediately removed during the time of survey and replaced with standard approved door locks.
The Director of maintenance and designees checked all other similar doors for deadbolt use, no there were identified.
The director of maintenance educated the staff of the maintenance department that the use of dead bolts would not be allowed.
during monthly compliance rounds appropriate locks on doors will now be added to the checklist. any unapproved locks will be replaced immediately.
The results of the monthly compliance rounds will be discussed/reviewed at the AQPI meeting.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous area enclosures on two of three floors.

Findings include:

Observation on February 21, 2024, between 10:00 a.m. and 12:03 p.m., revealed the following:

a. 10:00 a.m., second floor soiled laundry door, located near room C-211, had an open area around the hardware set.
b. 11:56 a.m., basement level, C Wing, tunnel rear exit door failed to latch into door frame.
c. 12:03 p.m., basement level, C Wing, laundry room soiled utility door self-closing device was broken.

Exit interview with the facility administrator and the facilities manager on Febraury 21, 2024, at 12:30 p.m., confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 04/15/2024

The identified area on second floor laundry room hardware set was corrected, with replacing it with one that fits.

The basement level door c wing exit door was corrected by replacing the latch.

The laundry room door in basement identified was replaced with a working self closing device.

The director of maintenance/designee will review all doors in the building to ensure closing and latching properly, and make necessary corrections immediately.

The director of maintenance will educate the department staff on checking doors for closing and latching as part of a daily routine.

The doors identified as needing to be corrected will be done as well as reported/discussed at the QAPI meetings.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors on two of three floors.

Findings include:

Observation on Febraury 21, 2024, between 10:15 a.m. and 11:45 a.m., revealed the following;

a. 10:15 a.m., second floor, sun room, right side door (standing in the corridor) failed to latch in the frame when tested.
b. 11:33 a.m., first floor, A1 commons dietary door, located near the dining room, failed to latch in the frame.
c. 11:35 a.m., first floor main kitchen door failed to latch in the frame.
d. 11:45 a.m., room 108, C-hall door failed to latch in the frame.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the corridor doors lacked positive latching.

Plan of Correction - To be completed: 04/15/2024

The identified sunroom door latch on second floor was repaired.

The following door identified: A1 common dietary was repaired to latch correctly.

The door the main kitchen was repaired to latch correctly.

The director of maintenance and designees examined all doors throughout the facility for latching correctly, any doors identified as not latching were repaired.

Added to maintenance rounds will be the checking of doors latching properly, this will be done on monthly basis.

The doors that were identified in need of repair and corrected will be discussed at QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, the facility failed to maintain one smoke barrier separation wall, affecting one of three floors.

Findings include:

Observation on Feburary 21, 2024, at 11:00 a.m., revealed a penetration in the smoke barrier separation wall, located above the door within A-1 commons, near the dining room.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the smoke barrier deficiency.

Plan of Correction - To be completed: 04/15/2024

The penetration identified in A1 commons wall, was repaired by director of maintenance.

A random check throughout the facility will be done by director of maintenance/ designee to identify any smoke penetrations issues, and any identified will be corrected using the proper material.

The director of maintenance will educated the maintenance staff on identifying smoke penetrations and correcting the issue when needed.

The monthly random checks to identify smoke penetrations and corrections will be discussed/reviewed at the QAPI meetings.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, the facility failed to maintain trash chutes on one of three floors.

Findings include;

Observation on February 21, 2024, at 10:55 a.m., revealed the trash chute door on B-2, second floor, failed to latch and the chute door frame was loose from the shaft wall.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the chute door lacked positive latching and the shaft was open at the frame.

Plan of Correction - To be completed: 04/15/2024

The identified trash chutes on B-2 was repaired.

The director of maintenance /designee checked all other trash chutes in the the facility to identify any failed latches or frames in need of repair, and corrected if needed.

The director of maintenance will educated the maintenance staff As part of daily maintenance rounds the checking of laundry chutes for latching and secured frames will be completed.

The repairs trash chutes will be discussed as the the amount of tie and which one to determine the root cause of being damaged at the QAPI meetings.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to monitor extension cord use on one of three floors.

Findings include:

Observation on February 21, 2024, at 11:10 a.m., revealed a multi-outlet extension cord in use near the A-bed in room B-211, second floor.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the multi-outlet cord was in use.

Plan of Correction - To be completed: 04/15/2024

The identified extension cord was removed at the time of survey.
A facility wide check by department heads/Designees took place to locate any other extension cords being used, and removed them if found.

An education by maintenance director on the dangers of using extension cord will be given to all staff in the facility.
In addition new admission paperwork will also emphasize the prohibited use of extension cords.
During daily ambassador rounds extension cords will be added to the check list and results will be discussed at morning stand up meeting.

The identification of extension cords being used will be reported at the QAPI meeting by the NHA.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain portable medical gas cylinder storage on one of three floors.

Findings include:

Observation on February 21, 2024, at 11:05 a.m., revealed an unsecured portable oxygen cylinder on the second floor, in the B-hall nurse station med-room.

Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the oxygen cylinder was free-standing.

Plan of Correction - To be completed: 04/15/2024

The portable O2 tank identified on B2 nurses station, was secured after it was identified during the survey.

A complete facility review by department heads/designee looking at each nursing station where O2 was being stored for compliance, any tanks out of compliance was immediately corrected.

The director of maintenance/ designee will educated all nursing staff regarding the proper storage of O2 tanks.

The daily ambassador audits will now include the checking of storage properly of O2 tanks.

The results of the daily rounds will be discussed at daily morning report and QAPI meetings

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #134902
Component 02
D Wing

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Aventura at Terrace View was in compliance with the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two-story, Type II (111), protected, non-combustible building, with a basement and rooftop mechanical spaces, that is fully sprinklered.

Plan of Correction:

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