Morningstar Residential Care Center
February 21, 2019 Certification/complaint Survey

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: 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)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2019
Corrected date: March 11, 2019

Citation Details

Based on record review and interviews during the Life Safety Code survey, the facility did not ensure the generator testing was maintained. Specifically, the monthly load test was not conducted at 30% or greater of the generator capacity and no fuel quality test was performed annually, as required. Findings include: Review on 2/21/2019 of the generator monthly load test reports dated from (MONTH) (YEAR) - (MONTH) 2019 revealed the tests were not conducted at equal to or greater than 30% of the generators' capacity (80 kilowatt). There were no load tests performed at greater than 30%. Specifically, the documented load tests were calculated to be 14% of the total kilowatt value. When interviewed on 2/21/2019 at 12:00 PM, the Facility Director stated he was not aware the generator was not running at 30% or greater during load tests. Review on 2/21/2019 of the annual generator vendor inspection report dated from 7/10/2018 did not indicate an annual load bank test or annual fuel quality test had been performed. When interviewed on 2/21/2019 at 12:00 PM, the Facility Director stated no load bank tests or fuel quality tests have ever been performed on the generator. 2012 NFPA 99: 6.4.4.1.1.3 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2019

NFPA 101 Electrical Systems-Essential Electric Systems. To meet the standard:
?Director of Environmental Services scheduled generator load test and fuel quality test. Director of Environmental Services (Designee) will ensure load test is conducted at 30 % to meet standard. Completion date: 03/11/2019
?All other required tests for generator met standard at time of survey.
To ensure that the practice does not recur:
? Director of Environmental Service and vendor have reviewed 2019 generator testing schedule. Load tests will be performed per regulatory standard and fuel testing will be performed as required.
To monitor corrective actions:
?Director of Environmental Services will provide quarterly report to QAPI committee on status of tests/ inspections.
The date for correction and the title of the person responsible.
?Responsible Party: Director of Environmental Services
?Completion Date: 03/11/2019

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: 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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2019
Corrected date: March 18, 2019

Citation Details

Based on record review and interview during the Life Safety Code survey, the facility's fire alarm system was not inspected/tested in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, there were no initiating devices inspected semi-annually or tested annually within the A-wing and basement of the facility for (YEAR), as required. Findings include: Review on 2/22/2019 of the facility's semi-annual fire alarm system inspection reports, dated 2/23/2018 and 8/3/2018, indicated that no initiating devices were inspected semi-annually or tested annually within the A-wing or basement of the facility during (YEAR). During an interview on 2/22/2018 at 10:50 AM, the Director of Environmental Services stated he was not aware initiating devices were not tested /inspected for the A-wing and basement of the building. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.4.5 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2019

NFPA 101 Fire Alarm System- Testing and Maintenance. To meet the standard:
?Director of Environmental Services scheduled inspection/ testing of initiating devices on A-wing and basement. Completion date: 03/18/2019
?All other initiating devices in building have been inspected/ tested and met standard at time of survey.
To ensure that the practice does not recur:
?2019 inspection calendar/ plan with outside vendor has been reviewed to ensure all initiating devices will be inspected/ tested per requirement.
?Director of Environmental Services (or Designee) will be onsite for scheduled inspections/ tests to ensure schedule is adhered to.
To monitor corrective actions:
?Director of Environmental Services will provide quarterly report to QAPI committee on status of tests/ inspections.
The date for correction and the title of the person responsible.
?Responsible Party: Director of Environmental Services
?Completion Date: 03/18/2019

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 21, 2019
Corrected date: March 11, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's exit discharge lighting was not maintained along the path to the public way for 1 of 8 emergency exits (exterior exit from A-wing). Specifically, the exit discharge did not have backup lighting and the pathway from A-wing exit to the main entrance (approximately 80 ft) was not arranged to be illuminated along the path to the public way. Findings include: When observed on 2/20/2019 at 12:30 PM, there was a single bulb light fixture at the A-wing exit with no back up lighting. In addition, there was no exterior lighting present and it was not arranged to be illuminated along the exit discharge pathway between the A-wing exit and the main entrance (approximately 80 feet). When interviewed on 2/20/2019 at 12:30 PM, the Director of Environmental Services stated the light fixture was old and only had one bulb in the fixture. He further stated there had never been exterior lighting between the A-wing exit and the main entrance. 2012 NFPA 101: 19.2.8, 7.8.1.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2019

NFPA 101 Illumination of Means of Egress. To meet the standard:
?Director of Environmental Services scheduled install for new exit sign equipped with back up battery to meet standard. Completion date: 03/11/2019
? Director of Environmental Services scheduled install for outdoor lighting to illuminate discharge pathway from A-wing to main entrance to meet standard. Completion date: 03/11/2019
?All other exit signs and exit discharge pathways have been inspected and met standard at time of survey.
To ensure that the practice does not recur:
?Exit signs and illumination of discharge pathways will be checked weekly to ensure standard is met.
To monitor corrective actions:
?Director of Environmental Services will provide quarterly report to QAPI committee on exit sign inspections/ illumination of discharge pathways.
The date for correction and the title of the person responsible.
?Responsible Party: Director of Environmental Services
?Completion Date: 03/11/2019