Nursing Investigation Results -

Pennsylvania Department of Health
ST. BARNABAS NURSING HOME
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. BARNABAS NURSING HOME
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ST. BARNABAS NURSING HOME - 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 April 25, 2019, at St. Barnabas Nursing Home, 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# 710302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 25, 2019, it was determined that St. Barnabas Nursing Home was not in compliance with the following requirements of the Life Safety Code for existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, TypeII (222), fire resistive building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility

Findings include:

1. Observation on April 25, 2019, at 9:00 a.m., revealed the facility lacked documentation verifying that a five year obstruction inspection of the automatic sprinkler system was performed.

Interview with the Maintenance Director on April 23, 2019, at 9:00 a.m., confirmed the five year obstruction inspection was not performed.




 Plan of Correction - To be completed: 05/02/2019

Assuming for the sake of this discussion, the validity of the deficiencies noted in the Department of Health's Statement of Deficiencies Report to St Barnabas Nursing Home, Inc. for the Survey ending April 25, 2019, which St. Barnabas does not admit, we offer the following Plan of Correction. Nothing contained in the Plan of Correction shall/should be deemed an admission, either expressed or implied, on the part of St. Barnabas Nursing Home, Inc as to the validity of the deficiencies noted in the report.


We have contacted the company that performs our quarterly inspections to verify that the five year obstruction inspection was completed. A record of the original quarterly inspection dated 12/17/15 in which the five year inspection was completed and noted by J & J Fire Protection. All future documentation will note the "Date Sprinkler Checked, Who provided the system test, and the water system supply source."

The Maintenance Director or designee will review each quarterly inspection documentation, when received, to ensure that the documentation clearly notes the completion of the Five-Year Obstruction Inspection is up to date. A QA will be completed, all results reviewed by the Quality Assurance Committee.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of fifteen smoke compartments.

Findings include:

1. Observation on April 25, 2018, at 10:15 a.m., revealed an unsealed wire penetration above the smoke barrier doors near room 113 on the first floor

Interview with the facility Administrator and Maintenance Director on April 25, 2019, at 1:00 p.m., confirmed the unsealed penetration.




 Plan of Correction - To be completed: 04/25/2019

The smoke barrier wall penetrations on the first floor near 113 have been fire caulked. The Maintenance Director of designee will complete routine rounds of the building to ensure that there are no smoke wall penetrations. A QA will be completed, all results will be reviewed by the Quality Assurance Committee.

Addendum: Penetration will be repaired with a UL approved through stop penetration system.
NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles for two of over 100 receptacles inspected.

Findings include:

1. Observation on April 25, 2019, revealed the following electrical outlets, within six feet of a sink, were not GFCI protected in the following dietary office:

a) 10:00 a.m., on the first floor;
b) 10:42 a.m., on the second floor

Interview with the Facility Administrator and Maintenance Director on April 25, 2019, at 1:00 p.m., confirmed the electrical receptacles were not GFCI protected.





 Plan of Correction - To be completed: 04/25/2019

These areas on the first and second floor refer to the Kitchenettes. The electrical outlets within these two areas have been changed over to GFCI outlets.
The Maintenance Director or designee will complete routine rounds of the building to ensure that all electrical outlets within 6 of a sink are protected by a GFCI outlet. A QA will be completed and all results will be reviewed by the Quality Assurance Committee.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator for two of two generators, affecting the entire facility.

Findings include:

1. Observation on April 25, 2019, at 11:00 a.m., revealed there was no emergency generator remote manual stop station located outside of the generator room.

Interview with the Facility Administrator and Maintenance Director on April 25, 2019, at 10:00 a.m., confirmed there was not a remote manual stop switch located outside of the generator room.






 Plan of Correction - To be completed: 06/24/2019

A remote manual stop will be installed for the generators (2) outside the building in which they are housed.
The Maintenance Director or designee will complete routine rounds to ensure that the remote stop is identified, and working as indicated. A QA will be completed, all results will be reviewed by the Quality Assurance Committee.


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