| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Drills and Emergency Preparedness.
(D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III
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12/20/2024
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| Fire Drills and Emergency Preparedness.
(E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. III
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12/20/2024
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| Complete Fire Alarm Systems.
(E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II
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12/20/2024
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| Sprinkler Systems.
(B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II
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12/20/2024
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| Interior Finish and Furnishings.
(D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II
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12/20/2024
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