NY State Tag

E

Deficiency in Fire Drill Documentation and Execution

Comprehensive Rehabilitation And Nursing Center AtWilliamsville, New York Survey Completed on 12-06-2024

Summary

The facility was found to be deficient in conducting and documenting fire drills as required by New York State law. The policy and procedure titled 'Fire Drill' mandates that drills be conducted quarterly across all shifts. However, during the Life Safety Code survey, it was discovered that the facility lacked documentation for a Second Shift fire drill in the Second Quarter of 2024. Additionally, there was no documentation for any fire drills conducted prior to May 10, 2024. The Maintenance Director confirmed that the previous Maintenance Director claimed to have conducted a fire drill but failed to submit the necessary paperwork, stating it was left in his car.

The review of Fire Drill Reports showed that drills were conducted on May 10, 2024, at 1:30 PM, and on June 28, 2024, at 11:10 PM. However, there was no evidence of a Second Shift drill in the Second Quarter, as required. This lack of documentation and failure to conduct the necessary drills on all shifts led to the citation under 10 NYCRR 415.29(a)(2), 711.2(a)(1), and 2012 NFPA 101 standards.

Plan Of Correction

Plan of Correction: Approved December 30, 2024

1. A review of all fire drills was completed by Maintenance Director and Administrator for the past year. All deficient practices were discussed and lack of paperwork was noted to QAPI.

2. All residents are at risk for deficient practices of not completing fire drills on all 3 shifts quarterly.

3. Administrator educated Maintenance Director/Maintenance Tech on Fire drills and holding each drill per shift quarterly.

4. Monthly audit of all fire drills will be conducted and brought to QAPI for further review. Any deficient practices will be corrected.

Person Responsible: Maintenance Director

Penalty

No penalty information released