Terrace View Long Term Care Facility
November 15, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard Survey completed on 11/15/18, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. One (Resident #77) of four residents reviewed for investigation of abuse had issues. Specifically, the resident had a scab on top of their left hand that was not reported or investigated by staff. The finding is: 1. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/15/18 documented that the resident was severely cognitively impaired and required 2-person assist for bathing and personal hygiene. The facility Policy and Procedure (P&P) entitled Bath and Skin Audit dated 2/2017 documented that a nurse and caregiver complete a skin check (bath) audit weekly at the time of the shower/ bath for any abnormalities. The facility P&P entitled Accident/ Incident Report, Resident dated 7/2017 documented that the facility is to maintain an accident and incident record which shall include a clear description of every accident and any other incident involving behavior of a resident or staff member that poses a concern for the resident's well-being. Observation on 11/9/18 at 7:27 AM revealed the resident had a scab on top of his left hand that measured approximately 1.0 centimeter (cm) long with purplish skin discoloration around it. Observation on 11/13/18 at 3:14 PM revealed the scab had reduced in size to approximately 0.5 cm and the skin surrounding it was a light purple color. Observation on 11/14/18 at 7:46 AM revealed that the scab was the same size. The Comprehensive Care Plan dated 9/4/18 documented that the resident was high risk for bleeding; to monitor signs or symptoms of bleeding to include inspecting the resident's skin. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 11/14/18 at 7:37 AM, LPN #1 revealed that staff did not report to her about any scab or skin tear on the resident's left hand. Further interview at 8:30 AM regarding the 11/8/18 and 11/12/18 MAR indicated [REDACTED]. During an interview on 11/14/18 at 7:45 AM, the Certified Nurse Aide (CNA) #1 assigned to the resident revealed she did not notice the scab on the resident's hand. During an interview on 11/14/18 at 7:46 AM, Registered Nurse (RN) Team Leader #1 revealed that she expects her staff to report any skin tear or scab found on a resident. She added that the resident has had so many skin tears she suspects her staff just didn't notice it and she will begin an investigation now. During an interview on 11/15/18 at 10:30 AM, the Director of Nursing revealed that she expects her staff to report a scab or skin tear or to at least ask about it. 415.4(b)(3)

Plan of Correction: ApprovedDecember 7, 2018

Please note: This Plan of Correction serves as a written allegation of compliance F 610 ?Çô Corrective Action ?Çô To assure that the facility has evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. 1) As noted in the finding, an accident and incident investigation was initiated on 11/14/18, and completed on 12/5/18 with no abuse, neglect, exploitation, or mistreatment noted. The staff member directly responsible for conducting the skin check on 11/12/18 (LPN #1) was inserviced on how to properly perform and document skin checks. 2) All residents in the facility have the potential to be effected by this practice. All residents will have their skin checked to assure they have no skin issues that have not been identified. 3) To ensure this practice does not reoccur, all nursing staff (licensed nurses and C.N.As) will be educated on how to properly perform through skin checks and report skin issues. In addition, the skin check policy will be reviewed and revised (if necessary). The Director of Nursing/Designee will oversee inservices for all nursing staff. 4) To ensure prevention of future deficient practice, The Director of Nursing/Designee will perform 40 skin check audits each month of random residents for the next 3 months and then as needed, based on the audit findings. Audits will include the validating that skin checks are accurate and will verify any new areas/previously unnoticed areas have associated accident and incident investigations initiated in accordance with 483.12(c)(3) . The Director of Nursing will monitor this process and will review the results monthly at the Quality Assurance & Performance Improvement meetings as needed. The Director of Nursing/Designee will assume overall responsibility for the correction of F 610

FF11 483.25(g)(4)(5):TUBE FEEDING MGMT/RESTORE EATING SKILLS

REGULATION: §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard Survey completed on 11/15/18, the facility did not ensure that a resident receiving enteral feeding receives appropriate care and services to prevent potential complications of enteral feeding. One (Resident #131) of two residents reviewed for feeding tubes had an issue involving proper positioning. Specifically, the resident remained lying flat during the administration of a bolus (a single meal liquid preparation given all at once) via a feeding tube. The finding is: 1. Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 9/5/18 documented the resident's cognition as severely impaired, required extensive assist to total dependence with all activities of daily living and is on a tube feeding. The facility policy and procedure entitled Assisted Nutrition and Hydration - Enteral Feeds revised 3/2017, documented its purpose to provide adequate assisted nutritional and homeostatic hydration intake to those residents who are unable to ingest adequate nutrients orally and to provide resident center care to residents who require assisted nutrition and hydration. The procedure documents to elevate the HOB (head of bed) at least 30 degrees unless otherwise ordered, and to keep the HOB elevated for ?½ hour after the feed and flush are completed. Review of the physician's orders [REDACTED]. - Free water flush 125 cc (cubic centimeter) with each feed dated 2/8/18. - The resident is NPO (nothing by mouth) dated 3/19/18. - [MEDICATION NAME] 1.5 calorie liquid (lactose-reduced food/fiber), give 280 cc, via [DEVICE] (a tube inserted through the abdomen that delivers nutrition directly to the stomach), every 4 hours dated 7/11/18. The Certified Nurse Aide (CNA) care guide, feeding guidelines documented the resident was total assist with feeding, NPO, Peg tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feed and may use wedge or up to Broda (tilt in-space) chair for feed. Observation of tube feed on 11/13/18 at 9:53 AM, with CNA #2 and Licensed Practical Nurse (LPN) #3 present revealed the resident was supine (lying flat on one's back, face upward) on his mattress when water flush, tube feed, and water flush, were administered, via the [DEVICE] by LPN #3. The resident was covered with his blanket and remained supine at the completion of the tube feed. During an interview on 11/13/18 at 10:06 AM, LPN #3 stated the resident always gets the tube feed lying down on the mattress in his room. During an interview on 11/14/18 at 1:12 PM, CNA #2 stated she was familiar with the resident's care plan. She will usually help the nurse, when it is time for his feed, especially if a float nurse is assigned from another unit. CNA #2 stated, I know we made a boo-boo yesterday, that was my fault. We didn't use the wedge pillow on him yesterday when he got his feed. We usually use the wedge pillow when he's getting his feed and when his feed is done we stay in there with him for a while so he can digest, but he usually won't stay on it when he's done. During an interview on 11/14/18 at 1:25 PM, Registered Nurse (RN) Unit Manager #2 stated, the expectation and standard practice for [DEVICE] feeds is he definitely should have been placed on the wedge pillow. We let him know it is time for his feed and put him on the wedge. When he is done we try to leave him on the wedge but sometimes he rolls right off. We do health teaching, that he should remain up right. During an interview on 11/14/18 at 1:40 PM, LPN #3 stated regarding the 11/13/18 [DEVICE] feed for Resident #131, I was so mad at myself, I didn't even see the wedge pillow. I saw it after I did his feed. He was lying flat, feeds are supposed to be at a 45-degree angle, I know that. I just didn't even think about it. During an interview on 11/ 15 /18 at 1:20 PM, the Director of Nursing stated for a resident on a tube feed, the HOB should be elevated. I expect that the staff would follow policy and the individual resident's plan of care. The risk of not elevating the head of bed when administering a tube feed is that it could lead to aspiration and pneumonia. 415.12 (g)(2)

Plan of Correction: ApprovedDecember 6, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 693 ?Çô Corrective Action ?Çô To assure that residents at the facility receiving enteral feeding receive appropriate care and services to prevent potential complications. 1) After the finding was noted, resident # 131 was assessed with [REDACTED]. The staff member (LPN #3) who administered the bolus feed, was educated on how to properly administer Bolus Feeds including the use of a wedge pillow if a resident in not in a bed where the head elevates. 2) All residents in the facility who receive enteral feeds have the potential to be effected by this practice. All residents who receive enteral feeds will be audited to assure their head is elevated during the treatment to prevent aspiration. 3) To ensure this practice does not reoccur, all licensed nursing staff (RNs and LPNs) will be educated on how to properly perform enteral feeding per policy and resident care plan. In addition, the enteral feeding policy will be reviewed and revised (if necessary). The Director of Nursing/Designee will oversee inservices for all licensed nursing staff. 4) To ensure prevention of future deficient practice, The Director of Nursing/Designee will perform 10 enteral feeding audits each month of random residents who received enteral feeding for the next 3 months and then as needed, based on the audit findings. Audits will include the validating that the residents head is elevated during the procedure and that the care plan is followed in accordance with 483.25(g)(5) . The Director of Nursing will monitor this process and will review the results monthly at the Quality Assurance and Performance Improvement meetings as needed. The Director of Nursing will assume overall responsibility for the correction of F 610 The facility files this Plan of Correction in compliance with regulatory requirements. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.

Standard Life Safety Code Citations

K307 NFPA 101:ALCOHOL BASED HAND RUB DISPENSER (ABHR)

REGULATION: Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey completed on 11/15/18, alcohol based hand sanitizer was not properly stored. Issues included quantities of alcohol based hand sanitizer, greater than ten gallons, were stored in a single smoke compartment and were not stored in a flammable liquids storage cabinet. This affected one (Ground Floor) of five resident use floors. The finding is: Per the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code and the 2012 edition of NFPA 30, Flammable and Combustible Liquids Code; quantities of alcohol based hand sanitizer greater than 10 gallons that are stored in a single smoke compartment must be stored in a flammable liquids storage cabinet. Observation on the Ground Floor on 11/9/18 at 9:25 AM revealed 77, 40.5 fluid ounce containers of alcohol based hand sanitizer, equivalent to 24.3 gallons, were stored on a shelf located in the Soiled receiving and sorting room, G-120. Further observation at this time revealed the active ingredient in the hand sanitizer was 62 percent alcohol. During the observation, the Facility Safety Supervisor stated the soiled receiving and sorting room was the main storage room for the building's supply of alcohol based hand sanitizer. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.6(5)(7) 2012 NFPA 30: 9.5, 9.5.2

Plan of Correction: ApprovedDecember 6, 2018

K 325 ?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association in regards to Alcohol Based Hand Rub Dispensers. 1) On 11/9/18 the 24.3 gallons of alcohol based hand sanitizer was re-distributed to other storage room so that there were less than 10 gallons in each. The Senior Storage Clerk was educated as to the proper storage of alcohol based hand sanitizer. 2) The Facility Safety supervisor will conduct an audit of all storerooms within the facility to assure that they do not contain more than 10 gallons of alcohol based hand sanitizer 3) The Administrator will oversee inservices for all Terrace View staff and appropriate contractors (dietary) on the importance of not storing more than 10 gallons of hand sanitizer in a single smoke compartment. 4) ) Routine Monthly audits of all storeroom will be performed for the next 3 months and then as needed based on the audit findings. Audits will verify that storerooms contain less than 10 gallons of alcohol based hand sanitizer in accordance with 2012 NFPA 101 19.3.2.6(5)(7). The Facility Safety Supervisor will monitor this process and will review the results monthly at the Quality Assurance & Performance Improvement meetings as needed. The Administrator will assume overall responsibility for K 325

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 11/15/18, hazardous area doors were not properly maintained. Issues included hazardous area doors were held open and obstructed from closing by devices that were not arranged to automatically close upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, and loss of power. This affected one (Ground Floor) of five resident use floors. The findings are: 1 a. Observation on the Ground Floor, on 11/9/18 at 7:33 AM, revealed the two corridor doors to the Central Supply Receiving room, GB-38 were in a fully open position and both doors were equipped with self-closing devices. Further observation at this time revealed the left side door, as one looked at the room from the corridor, had a cardboard box stored in front of it obstructing the door from closing. Continued observation at this time revealed the right side door, as one looked at the room from the corridor, had a three-inch long by one-half inch wide piece of wood wedged between the door and its frame preventing the door from closing. The observation also revealed the Central Supply Receiving room was greater than 50 square feet in size and was being used to store 80 cases of disposable briefs, 20 cases of vinyl exam gloves, five cases of catherization trays, five cases of [MEDICAL CONDITION] care sets, and four cases of gauze bandages. During the observation, the Facility Safety Supervisor stated he had previously spoken to the staff about blocking doors. b. Observation on the Ground Floor, on 11/9/18 at 7:47 AM, revealed the corridor to the Housekeeping supply room, GB-48 was in a fully open position and the door was equipped with self-closing device. Further observation at this time revealed a four-inch long by one-half-inch wide piece of wood was wedged under the door, obstructing the door from closing. Continued observation at this time revealed the Housekeeping supply room was greater than 50 square feet in size and was being used to store 23 cases of paper towels, 50 packages of toilet tissue, 28 cases of trash can liners, and two, six-foot tall by five-foot long by two-foot wide racks full of cleaning products. During the observation, the Facility Safety Supervisor stated staff knew they were not to block doors. c. Observation on the Ground Floor, on 11/9/18 at 9:19 AM, revealed a one-half-inch gap between the corridor doors to the Soiled receiving and sorting room, G-120. Further observation at this time revealed the right door, as one looked at the room from the corridor, was equipped with a self-closing device and had five, one and one-half-inch round metal washers attached to it with a screw. These washers were preventing the right door from latching into the left door. Continued observation at this time revealed the room was greater than 50 square feet in size and was being used to store 77, 40.5 fluid ounce alcohol based hand sanitizer dispenser refills, four, six-foot tall by four-foot long by two-foot wide racks full of paper towels, toilet tissue, trash can liners, laundry detergent, cleansers, hand soap dispenser refills, and mop heads. During the observation, the Facility Safety Supervisor stated he was not aware the doors were not latching into each other and the doors must have been hit by a cart. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.2

Plan of Correction: ApprovedDecember 6, 2018

K 223 ?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association in regards to doors with self-closing devices. 1) On 11/9/18 the obstructions (Cardboard box and piece of wood) of the two corridor doors to room GB-38 were removed and the doors closed properly. On 11/9/18 the obstruction (piece of wood) of the corridor door to room GB-48 were removed and the door closed properly. On 11/9/18 the obstruction (washers) of the corridor door to room G-120 were removed and the one half inch gap to the door was corrected. The door was tested and latched properly. 2) The Facility Safety supervisor will conduct an audit of all doors with self-closing devices within the facility to assure that they are unobstructed and close and latch properly. 3) The Administrator will oversee inservices for all Terrace View staff and appropriate contractors (dietary) on the importance of not propping or restricting doors with self-closing devices. The Terrace View Plant Operations staff will also be inserviced on the importance of properly maintaining these doors. 4) Routine Monthly audits of all doors with closing devices will be performed for the next 3 months and then as needed based on the audit findings. Audits will verify that all doors with closing devices are unobstructed latch are in accordance with 2012 NFPA 101 19.2.2.2.7. The Facility Safety Supervisor will monitor this process and will review the results monthly at the Quality Assurance & Performance Improvement meetings as needed. The Administrator will assume overall responsibility for K 223

EP TRAINING PROGRAM

REGULATION: §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 11/15/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, four of four Certified Nurse Aides (CNAs) interviewed for knowledge of emergency procedures lacked basic knowledge of the emergency procedures. The finding is: 1. During an interview on 11/9/18 at 4:00 PM, the Administrator stated all employees have been trained on the topic of emergency preparedness. Also at this time, the Administrator stated he would expect each CNA to know everything on the emergency preparedness competency training test, which includes basic things about emergency preparedness, such as the facility has a written emergency preparedness plan, what topics the plan covers and where copies of the plan are kept. He additionally stated each CNA should know that the facility uses plain language in announcing all types of emergency situations, where to report for the labor pool, where the Command Center would be located in an emergency, and have a basic knowledge of what the Incident Command System is and what their role would be. He added that all staff have been trained on what the Incident Command System is, and CNAs should have a basic knowledge of it, but managers receive more advanced training, and should understand it more thoroughly. Interview with randomly-chosen CNAs, regarding their knowledge of emergency procedures, on 11/9/18 from 2:30 PM until 3:05 PM revealed the following: - CNA-A on the Front Park unit stated she could not recall any training about emergency preparedness, and stated Code Red was the way the facility announced a fire emergency. She immediately added that she was not sure about Code Red. - CNA-B on the Front Park unit stated she recently attended an eight-hour training on handling combative residents, but could not recall any training on emergency preparedness. CNA-B also stated Code Red was the way the facility announced a fire emergency, and immediately added that she was not sure about Code Red. When asked if she had heard of the Incident Command System, CNA-B replied that she had not. - CNA-C on the Delaware Park unit stated she has worked at this facility since (MONTH) (YEAR) and stated she had not attended any trainings about emergency preparedness and could not recall the topic of emergency preparedness being discussed at General Orientation. When asked what code phrase or plain language phrase is used to announce a fire emergency at this facility, CNA-C replied that she could not recall. - CNA-D in the Central Corridor stated she has worked at this facility for one year and that she had not attended any trainings for emergencies or natural disasters, but it was probably discussed at the time of her hire, but she cannot remember it now. When asked what code phrase or plain language phrase is used to announce a fire emergency at this facility, CNA-D replied that is was Code Red, and when asked if she had heard of Incident Command System or Mutual Aid Plan (a local network of long term care facilities that agree to help each other during an emergency, which this facility is a member), CNA-D replied that she had not. Record review of the facility's written emergency preparedness plan, called Emergency Preparedness Program, revised 2/9/18, revealed plain language is used in the announcement of an emergency situation, such as Code Fire Alarm Activation to announce a fire. Record review of the sign-in sheets from an in-service called, Survey Prep (YEAR) and Plain Language/ Emergency Preparedness held on 5/4/18 revealed CNAs B and D attended. Record review of the sign-in sheet from an in-service called, New Hire Orientation held on 5/15/18 revealed CNA-C attended. Additional record review of CNA A's Annual Master CNA Skills Verification Log (YEAR) revealed the topics called, Fire Alarm Activation and Incident Command/ Disaster Plan were covered on 8/2/18. Per Centers for Medicare and Medicaid Services (CMS), Long Term Care facilities must do all of the following: I. Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. II. Provide emergency preparedness training at least annually. III. Maintain documentation of the training. IV. Demonstrate staff knowledge of emergency procedures. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(d)(1)

Plan of Correction: ApprovedDecember 6, 2018

Please note: This Plan of Correction serves as a written allegation of compliance E 037 ?Çô 1) Corrective Action ?Çô To assure that the facility staff demonstrates knowledge of emergency procedures. 1) As noted in the finding, CNA?ÇÖs A,B.C, and D were educated on the disaster plan/plain language on 8/2/18, 5/4/18, 5/15/18, and 8/2/18 respectively. CNA?ÇÖs A,B,C, and D were re-educated on the disaster plan and plain language use for emergency procedures. 2) All residents have the potential to be effected by this deficient practice. 3) Our Emergency Preparedness Plan/ Competency will be reviewed and revised (if necessary) to ensure staff understanding/compliance of the use of plain language. The Inservice department/designee will in-service all Terrace View staff on plain language use for emergency procedures and the disaster preparedness plan. 4) To ensure prevention of future deficient practice, The Inservice Department/Designee will perform audits of 40 random Staff members a month for the next 3 months and then as needed based on the audit findings. Audits will verify that all staff have a basic understanding of the emergency disaster plan and plain language use for emergencies in accordance with 483.73(d)(1). The Administrator will monitor this process and will review the results monthly at the Quality Assurance & Review meetings as needed. The Administrator will assume overall responsibility for the correction of E 037. The facility files this Plan of Correction in compliance with regulatory requirements. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

Based on interview and record review during the Life Safety Code survey completed on 11/15/18, a risk assessment was not conducted on the building's systems. Issues included, the facility did not conduct a defined and documented risk assessment for the building system categories in accordance with National Fire Protection Association (NFPA) 99 - Health Care Facilities Code. This affected five (Ground, First, Second, Third, and Fourth Floors) of resident use floors and one of one Penthouse. The finding is: 1. Per the 2012 edition of NFPA 99, Health Care Facilities Code: building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code and the categories shall be determined by following and documenting a defined risk assessment procedure. During an interview on 11/15/18 at 12:35 PM, the Facility Safety Supervisor stated he did not have documentation that a risk assessment had been completed for building system's categories. During an interview on 11/15/18 at 1:12 PM, the Administrator stated he was not aware of the regulation that health care facilities had to conduct a risk assessment for the building system categories in accordance NFPA 99 - Health Care Facilities Code. The Administrator further stated the facility had no documentation a risk assessment had been conducted on the building system's categories, in accordance with NFPA 99. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 4.1, 4.2, 4.3

Plan of Correction: ApprovedDecember 6, 2018

K 901 ?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association in regards to Fundamentals ?Çô Building System Categories 1) The risk assessment procedure NFPA 99 will be performed for the building and electrical/gas equipment. Associated plans will be developed (if necessary) for assessed risks. 2)All residents have the potential to be affected by this practice. 3) The Administrator will oversee inservices for the Facility Safety Supervisor on the importance of performing the NFPA 99 Risk Assessment annually. 4) The NFPA 99 Risk assessment will be added to the facility Disaster Plan and will be reviewed on an annual frequency. The Facility Safety Supervisor will monitor this process and will review the results/concerns as need at the monthly Quality Assurance & Performance Improvement meetings to maintain compliance with 2012 NFPA 99:4.1,4.2, 4.3. The Administrator will assume overall responsibility for K 901.

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - OTHER

REGULATION: Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey completed on 11/15/18, oxygen shut off zone vales were not properly maintained. Issues included, oxygen shut-off zone vales were not readily accessible. This affected one (Fourth Floor) of five resident use floors. The finding is: 1. Observation on the Fourth Floor, on the Ellicott Square unit, on 11/8/15 at 9:44 AM, revealed a medication cart was stored in front of and obstructing the oxygen shut off zone vales for rooms; 4B-10, 4B-12, 4B-13, 4B-15, 4B-16, 4b-19, 4B-20, 4B-23, 4B-37, 4B-39, 4B-40, 4B-41, 4B-42, 4B-43, 4B-46, 4B-47, and 4B-49. Further observation at this time revealed a sign posted on the wall to the right of the shut vales read as follows: Do not place Med/ Treatment cart in front of 02 panel. During the observation, the Fire Safety Supervisor stated the facility's staff knew they cannot block the oxygen shut off valves. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 5.1.4.8.7

Plan of Correction: ApprovedDecember 6, 2018

K 902 ?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association in regards to Gas and Vacuum Piped Systems: 1) On 11/8/18 the medication cart that was stored in front of the Oxygen shutoff valve located on the Ellicott Square unit was relocated so that it was no longer obstructing the valve. 2) The Facility Safety supervisor will conduct an audit of all oxygen shut off valves within the facility to assure that they free from any obstructions. 3) The Administrator will oversee inservices for all Terrace View staff and appropriate contractors (dietary) on the importance of not obstructing oxygen shut off valves. 4) ) Routine Monthly audits of all oxygen shut off valves will be performed for the next 3 months and then as needed based on the audit findings. Audits will verify that Oxygen shut off valves are free from obstruction and properly maintained in accordance with 2012 NFPA 101 99: 5.1.4.8.7. The Facility Safety Supervisor will monitor this process and will review the results monthly at the Quality Assurance & Performance Improvement meetings as needed. The Administrator will assume overall responsibility for K 902

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 11/15/18, oxygen cylinders were not properly maintained. Issues included oxygen cylinders were not properly secured, oxygen cylinders were stored in a room that did not have signage indicating oxygen was being stored in the room, and oxygen cylinders were stored too closely to combustible materials. This affected two (Ground and Second Floors) of five resident use floors. The findings are: 1. Observation on the Ground Floor, on 11/9/18 at 9:33 AM, revealed five D-size oxygen cylinders in nylon carrying cases were each individually stored hanging from hooks, two feet above the floor's surface, on the back of the handles of five, two-wheeled oxygen carts located in the Oxygen tank storage room, GB-44. Further observation at this time revealed each of the oxygen cylinders were hung from the hook by the strap on the cylinders' nylon carrying cases. Continued observation at this time revealed one of the two-wheeled carts also had a C-size oxygen cylinder stored free standing, upright, and unsecured on top of its base. Observations also revealed the room contained 152 E-size oxygen cylinders, five D-size oxygen cylinders, one C-size oxygen cylinder, two H/K-size nitrogen cylinders, and one H/K-size helium cylinder. During the observation, the Facility Safety Supervisor stated he was not aware the oxygen cylinders were stored hanging from the two-wheeled carts and the cylinders had come into the facility when residents had been transported from the hospital. 2. Observation on the Ground Floor, on 11/9/18 at 9:48 AM, revealed two E-size oxygen cylinders in portable vent carts were stored in the Maintenance Shop, room GB-45. Further observation at this time revealed the two oxygen cylinders were stored within one-foot of cardboard boxes containing [MEDICATION NAME], parts for mechanical beds and a cart containing painting supplies including drop cloths. Continued observation at this time revealed the room's door and area around the door on the corridor side, did not have signage posted stating oxygen was being stored in the room. During the observation, a Biomed Technician stated the oxygen cylinders had been in the room for three to four days. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 11.3.2, 11.3.2.3(2), 11.3.4.1, 11.3.4.2, 11.3.2.6, 11.6.2.3(1)(11)

Plan of Correction: ApprovedDecember 6, 2018

K 923?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association pertaining to Gas Equipment ?Çô Cylinder and Container storage. 1) On 11/9/18, the Plant operations department removed the 5 nylon carrying cases from the oxygen storage room GB-44 and assured the that all cylinders were then properly secured with the oxygen storage racks. On 11/9/18, the Plant operations department also removed the 2 E-size oxygen cylinders that were stored in the Maintenance shop - room GB-45 and were placed in an appropriate Oxygen storage room with the correct signage. 2) The Maintenance Supervisor will conduct a complete inspection of all rooms within the facility to ensure that all oxygen is stored in compliance of the life safety code. 3) The Administrator will oversee inservices for all Terrace View staff on how to properly store oxygen cylinders. 4) 15 random room audits will be conducted Monthly for three months and then as needed to ensure compliance with the life safety code. The audits will verify that oxygen is stored appropriately in accordance with 2012 NFPA 99: 11.3.2, 11.3.2.3(2). The Facility Safety Supervisor will monitor this process and review the results as needed at the Quality Assurance & Performance Improvement meetings. The Administrator will assume overall responsibility for the correction of K 923. The facility files this Plan of Correction in compliance with regulatory requirements. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest

K307 NFPA 101:GENERAL REQUIREMENTS - OTHER

REGULATION: General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 11/15/18, the facility did not maintain the building to minimize the possibility of a fire emergency requiring the evacuation of occupants. Issues included a flammable liquid and a flammable gas were stored in areas that were not protected as hazardous areas. This affected one (Ground Floor) of five resident use floors. The findings are: 1. a. Observation on the Ground Floor, on 11/8/18 at 3:17 PM, revealed a 16-fluid ounce can of [MEDICATION NAME] was stored on a cart in the Ophthalmology Clinic, room GD-46. Further observation at this time revealed the following was written on the can's label: Danger: Extremely flammable liquid, vapor may cause flash fire or ignite explosively. Vapors may travel long distances to other areas and rooms away from work site. Keep away from heat, sparks, flame, and all other sources of ignition. Use only with adequate ventilation to prevent buildup of vapors. If the work area is not well ventilated do not use product. Continued observation, at this time, revealed the door to the Ophthalmology Clinic would not self-close and latch into its doorframe and it was not equipped with a self-closing device. The observation also revealed the Ophthalmology Clinic was located within the Clinics suite, room GD-43, and the Clinics suite corridor door was not equipped with a self-closing device. During the observation, the Facility Safety Supervisor stated he was not aware the can of [MEDICATION NAME] was stored in the room. b. Observation on the Ground Floor, on 11/8/18 at 3:32 PM, revealed a six-inch tall by three-inch long by two and one-half inch wide butane torch was stored in a drawer in the Dental Clinic, room GD-48. Further observation at this time revealed the following was written on the torch's gas canister: Extremely flammable contains butane gas. Continued observation at this time revealed door to the Dental Clinic would not self-close and latch into its frame and it was not equipped with a self-closing device. The observation also revealed the Dental Clinic was located within the Clinics suite, room GD-43, and the Clinics suite corridor door was not equipped with a self-closing device. During the observation, the Facility Safety Supervisor stated he was not aware the butane torch was stored in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.1.1.3.1, 19.1.1.3.2, 4.6.12.1

Plan of Correction: ApprovedDecember 6, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Please note: This Plan of Correction serves as a written allegation of compliance. K 100 ?Çô The facility will ensure that it meets all the applicable requirements of National Fire Protection Association 101 pertaining to general requirements. 1) On 11/8/18, the facility safety supervisor removed the can of [MEDICATION NAME] from the Ophthalmology clinic (room GD-46) and stored on a properly protected area. The Ophthalmology staff was educated not to leave highly flammable liquids in non-protected areas and how to properly store that item. On 11/8/18, the facility safety supervisor removed the butane torch from the Dental clinic (room GD-48) and stored on a properly protected area. The Dental staff was educated not to leave highly flammable gases in non-protected areas and how to properly store that item. 2) The Facility Safety supervisor will conduct a complete inspection of all resident rooms/facility offices to assure no other highly flammable liquids/gases are being stored improperly in non-protected areas. 3) The Administrator/Designee will review and revise (if necessary) the facilities hazardous Materials Management Plan. In addition, all staff and appropriate contractors (Dietary, Dental, Ophthalmology) will be in serviced on how and where to store highly flammable liquids/gases. 4) 15 random Monthly audits of all facility offices and resident rooms will be performed for three months and then as needed to ensure compliance with the life safety code. The Facility Safety Supervisor will monitor this process and review the results as needed at Quality Assurance & Performance Improvement meetings. The Administrator will assume overall responsibility for the correction of K 100

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 15, 2018
Corrected date: January 14, 2019

Citation Details

Based on observations and interview during the Life Safety Code survey completed on 11/15/18, stairways were not properly maintained. Issues included, items were being stored in a stairway. This affected one (Stair C) of nine stairways. The finding is: 1. Observation on the Ground Floor, on 11/9/18 at 7:48 AM, revealed three housekeeping carts, covered with sheets, were stored in the Stair C Stairway. Further observation at this time revealed the Stair C Stairway served the Ground, First, Second, Third, and Fourth Floors. During the observation, the Facility Safety Supervisor stated he had previously told the housekeeping staff they could not store their carts in the stairways. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.3, 7.2.2, 7.2.2.1.1, 7.1, 7.1.3.2.3

Plan of Correction: ApprovedDecember 6, 2018

K 225 ?Çô The facility will ensure that it meets all the applicable requirements of the Life Safety Code of the National Fire Protection Association in regards to Stairwell and Smoke Proof enclosures. 1) On 11/9/18 the Housekeeping carts stored in stairwell C were removed, and the housekeeping staff who placed them there were educated on proper storage of the carts when not in use. 2) The Facility Safety supervisor will conduct an audit of all stairwells within the facility to assure that they are properly maintained and free from any stored items. 3) The Administrator will oversee inservices for all Terrace View staff and appropriate contractors (dietary) on the importance of not storing items within stairwells. 4) ) Routine Monthly audits of all stairwells will be performed for the next 3 months and then as needed based on the audit findings. Audits will verify that stairwells are free from stored items and properly maintained in accordance with NFPA 101 7.2.18.2.2.3. The Facility Safety Supervisor will monitor this process and will review the results monthly at the Quality Assurance & Performance Improvement meetings as needed. The Administrator will assume overall responsibility for K 225