Failure to Maintain Self-Closing Mechanism on Laundry Chute Door
Summary
The facility failed to maintain proper self-closing mechanisms on a vertical opening door, specifically the basement laundry chute door. During an observation, it was found that the chute door did not have the required number of fusible links on its hold-open springs, with only one of the two necessary fusible links installed. This deficiency prevented the chute door from closing as required. The issue was confirmed in an interview with the administrator and maintenance supervisor.
Plan Of Correction
Fusible link replaced immediately at time of survey. Weekly audits to ensure fusible link is installed will be completed by Maintenance or designee weekly for four weeks. After four weeks, audits will continue monthly. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Penalty
The facility failed to maintain the required fire resistance rating for vertical openings, affecting two levels. The stairway between the Lower Level Kitchen and the First Floor lacked one-hour fire resistive construction. Additionally, the north side exit from the Basement had a staircase with unsheathed walls, lacking the required fire resistance. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director.
The facility failed to maintain proper vertical opening enclosures, as unsealed openings were found in a bathroom pipe chase wall on two unoccupied floors. This was due to ongoing work to replace a leaking drain pipe, affecting two smoke compartments. The issue was confirmed by the Facility Administrator and Maintenance Director.
The facility did not maintain the fire resistance rating of vertical openings on the tenth floor. An observation revealed that the rated access ceiling door in the Electrical Closet next to room 1020 failed to self-close and latch, as confirmed by the Maintenance Director.
The facility did not maintain the required fire resistance rating for vertical opening enclosures, affecting one smoke compartment. Observations revealed multiple wires passing through a large open hole in Room U 115, confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the required fire resistance rating for vertical enclosures, affecting all six floors. Observations revealed that HVAC shafts adjacent to exit stair towers lacked the necessary two-hour fire resistance. Additionally, the Clay Street exit stair tower on the fourth and fifth floors had inadequate construction, with insufficient drywall and unprotected steel beams. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain fire safety for a vertical opening between two floors. The self-closing devices were removed from the Private Dining Room's double doors, which are part of a one-hour, two-story vertical opening. This deficiency was confirmed during an interview with the Facility Administrator and Facilities Manager.
Failure to Maintain Fire Resistance Rating for Vertical Openings
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical openings, specifically affecting two levels within the building. During a document review and interview conducted on March 17, 2025, it was discovered that the communicating stairway between the Lower Level Kitchen and the First Floor did not have the necessary one-hour fire resistive construction. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, the facility did not maintain the fire resistance rating for stair towers, impacting one of two floors within the building. A document review revealed that the north side exit from the Basement was a communicating staircase with walls not sheathed on the room 2A side, lacking the required one-hour fire resistance rating. This issue was also confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee. The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Failure to Maintain Vertical Opening Enclosures
Penalty
Summary
The facility failed to maintain proper vertical opening enclosures, as evidenced by an observation on February 6, 2025. During the inspection, it was noted that floors five and seven, which were unoccupied at the time, had multiple unsealed openings in a bathroom pipe chase wall. These openings were present due to ongoing work to replace a leaking drain pipe. This deficiency affected two out of twelve smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Unsealed openings on floors 5 and 7 will be repaired by 3/21/2025. House audit will be completed by Maintenance Director or designee on unsealed openings. The administrator or designee will reeducate Maintenance Director on unsealed openings - K311. Identified rooms will be inspected for new openings monthly by the Maintenance Director or designee. Findings will be reported to Quality Assurance and Performance Improvement committee meetings.
Failure to Maintain Fire Resistance Rating on Tenth Floor
Penalty
Summary
The facility failed to maintain the fire resistance rating of vertical openings, specifically affecting the tenth floor. During an observation on February 4, 2025, at 10:40 a.m., it was noted that the rated access ceiling door in the Electrical Closet next to room 1020 did not self-close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director at 1:00 p.m. on the same day.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Spring will be reset on ceiling door to ensure latching and ability to close. Ceiling door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Vertical Opening Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical opening enclosures, specifically affecting one of the 15 smoke compartments. During an observation, it was noted that multiple data, cable, and electrical wires were passing through a large open hole in the back corner of Room U 115. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director, who acknowledged the issue with the vertical opening enclosure.
Plan Of Correction
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 January 23, 2025, 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 the proper electrical tray and fire blocking material around cables, data lines, and electrical wires in U115 on or before March 14, 2025. 2. Director of maintenance or designee will perform a one-time audit of the building ensuring all data, cable, and electrical wires passing through vertical openings are properly sealed. 3. Results of the audit will be reviewed in QA.
Inadequate Fire Resistance in Vertical Enclosures
Penalty
Summary
The facility failed to maintain the required fire resistance rating for multiple vertical enclosures, affecting all six floors. During an observation on January 7, 2025, it was noted that the vertical enclosures protecting the HVAC shafts adjacent to the exit stair towers did not meet the necessary two-hour fire resistance rating. Additionally, the construction of the Clay Street exit stair tower on the fourth and fifth floors was found to be inadequate, consisting of two sheets of drywall on the inside and one sheet on the corridor and resident room side of metal studs, with unprotected steel beams included as part of the enclosure. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Vertical Opening Fire Safety Deficiency
Penalty
Summary
The facility failed to maintain proper fire safety measures for a vertical opening between two floors. During an observation on December 23, 2024, it was noted that the self-closing devices had been removed from the double doors of the Private Dining Room. These doors are part of a one-hour, two-story vertical opening, which is required to have a fire resistance rating of at least one hour. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. The plan of correction is prepared and executed as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements. Door closer has been installed on the Private Dining Room door. Door closers throughout the facility have been audited and are working properly. NHA/Designee educated the Maintenance Director on NFPA 101 Hazardous Areas-Enclosures. Maintenance Director will randomly audit door closures 1x week for 4 weeks then monthly x2.
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