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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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 February 14, 2024, 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 February 14, 2024, 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, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview it was determined the facility failed to install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of fifteen smoke compartments. In accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1.

Findings include:

1. Observation on February 14, 2024, at 9:30 a.m., revealed a wheeled gas-fired range cooktop located on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system, after it had been moved for maintenance and cleaning.

Interview with the Facility Administrator and Maintenance Director on February 14, 2024 at 1:00 p.m., confirmed the gas appliance did not have an approved method to ensure it is correctly placed under the hood and fire suppression system.

Plan of Correction - To be completed: 04/06/2024

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 February 14 ,2024 , 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.

1. Facility maintenance will Purchase and install commercial kitchen appliance alignment devices for all wheeled appliances under the kitchen hoods on or before April 5th 2024.
2. Director of maintenance or designee will perform a one time audit of kitchen appliances to ensure alignment devices are installed for all wheeled appliances.
3. Results of audit will be reviewed in QA

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform fire alarm system inspection and testing, in two instances, affecting the entire facility.

Findings Include:

1. Review of documentation on February 14, 2024, revealed the facility lacked documentation for the following required fire alarm system maintenance and testing:

a) 9:15 a.m., an annual fire alarm system inspection;
b) 9:16 a.m., a semi-annual visual inspection.

Interview with the Facility Administrator and Maintenance Director on Febraury 14, 2024, at 1:00 p.m, confirmed the facility lacked documentation for inspection and testing of the fire alarm system, at the time of the survey.

Plan of Correction - To be completed: 02/15/2024

A.
1. Director of maintenance has Obtained records of the fire Alarm system annual maintenance and Testing on February 15th 2024. Records are readily available.

2. Director of maintenance or designee will perform semiannual audits of fire alarm maintenance and testing to ensure records and readily available

3. Results of audit will be reviewed in QA
B.
1. Director of maintenance has Obtained records of the fire Alarm system annual maintenance
and Testing on February 15th 2024. Records are readily available.

2. Director of maintenance or designee will perform semiannual visual audits of fire alarm maintenance and testing to ensure records and readily available

3. Results of audit will be reviewed in QA

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 four instances, affecting four of fifteen smoke compartments.

Findings include:

1. Observation on February 22, 2023, revealed the following sprinkler deficiencies:

a) 9:15 a.m., there were gaps greater than 1/8" in the ceiling tile of the kitchen;
b) 9:50 a.m., there was conduit resting on the sprinkler lines above the ceiling outside the ladies room in the basement;
c) 10:20 a.m., there were gaps greater than 1/8" in the ceiling tile of the chapel in the basement;
d) 10:45 a.m., there was a gap greater than 1/8" in the ceiling tile surrounding the standpipe outside resident room 207.

Interview with the Facility Administrator and Maintenance Director on February 14, 2024, at 1:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/06/2024

A.
1. Facility maintenance will repair gaps in kitchen ceiling greater than 1/8" with but not limited to tighter fitting ceiling tile and /or caulking. On or before April 5th 2024.

2. Director of maintenance or designee will perform quarterly audits of kitchen ceiling to ensure no penetrations or gaps in ceiling
3. Results of audit will be reviewed in QA
B.
1. Facility maintenance will remove and correctly support conduit resting on sprinkler lines outside ladies' room in the basement on or before April 5th 2024.

2. Director of maintenance or designee will perform random monthly audits of smoke compartments to insure no wires, conduit or other object are resting on sprinkler lines.

3. Results of audit will be reviewed in QA

C
1. Facility maintenance has repaired gaps in Basement Chapel ceiling greater than 1/8" with but not limited to tighter fitting ceiling tile and /or caulking. On February 20th 2024

2. Director of maintenance or designee will conduct quarterly inspections of the basement chapel for gaps in the ceiling.

3. Results of audit will be reviewed in QA

D
1. Facility maintenance has made repairs to the gap around standpipe outside of room 209 with new ceiling tile and caulking on February 20th 2024.

2. Director of maintenance or designee will conduct quarterly inspections of facility to ensure no gaps are present in ceilings.

3. Results of audit will be reviewed in QA

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of fifteen smoke compartments.

Findings include:

1. Observation on February 14, 2024, at 11:45 a.m., revealed there was no fire extinguisher in the elevator mechanical room in the chapel hallway.

Interview with the Facility Administrator and Maintenance Director on February 14, 2024, at 1:00 p.m., confirmed the above portable fire extinguisher deficiency.

Plan of Correction - To be completed: 02/16/2024

1. Facility maintenance installed a fire extinguisher in the elevator mechanical Room on February 16th 2024

2. Maintenance director or designee will perform a onetime inspection of facility To ensure fire extinguishers are present in mechanical rooms.

3. Results of audit will be reviewed in QA

NFPA 101 STANDARD Electrical Systems - Receptacles:

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 one of over 100 receptacles inspected.

Findings include:

1. Observation on February 14, 2024, at 11:24 a.m., revealed an electrical outlet within six feet of a sink in med room on the second floor was not GFCI protected

Interview with the Facility Administrator and Maintenance Director on February 14, 2024, at 1:00 p.m.., confirmed the electrical receptacle was not GFCI protected.

Plan of Correction - To be completed: 04/06/2024

1. Facility maintenance will order materials and install GFIC outlet protection on outlets in 2nd floor north medication room on or before April 5th 2024

2. Director of maintenance or designee will perform a one-time audit of facility to ensure all Electrical outlets located within six feet of a water source are GFIC protected.

3. Results of audit will be reviewed in QA

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, in two instances, affecting the entire facility.

Findings Include:

1. Review of documentation on February 14, 2024, revealed the facility lacked documentation for the following required emergency generator maintenance and testing:

a) 9:30 a.m., annual maintenance and testing;
b) 9:32 a.m., an annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director on Febraury 14, 2024, at 1:00 p.m, confirmed the facility lacked documentation for inspection and testing of the emergency generator, at the time of the survey.

Plan of Correction - To be completed: 02/15/2024

A.
1. Director of maintenance has received documentation of annual testing and maintenance of emergency generators on February 15th 2024. Document are readily available.

2. Director of maintenance or designee will perform semiannual audits of Emergency generator documentation to ensure current inspection and maintenance records and are readily
available

3. Results of audit will be reviewed in QA

B.
1. Director of maintenance has received documentation of annual fuel quality testing of emergency generator fuel on February 15th 2024. Document are readily available.

2. Director of maintenance or designee will perform semiannual audits of Emergency generator documentation to ensure current annual fuel testing records and are readily available

3. Results of audit will be reviewed in QA

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