| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Exits, Stairways, and Fire Escapes.
(H) Outside stairways shall be constructed to support residents during evacuation and shall be continuous to the ground level. Outside stairways shall not be equipped with a counter-balanced device. They shall be protected from or cleared of ice or snow. II/III
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10/30/2023
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| Protection from Hazards.
(J) In all facilities that were initially licensed on or prior to December 31, 1987, and all facilities licensed for twenty (20) or fewer beds prior to August 28, 2007, each smoke section shall be separated by a one- (1-) hour fire-rated smoke partition that extends from the inside portion of an exterior wall to the inside portion of an exterior wall and from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces. Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspending ceiling system where the following conditions are met: The ceiling system forms a continuous membrane, a smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling and the space above the ceiling is not used as a plenum. Smoke partition doors shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II
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10/30/2023
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| Smoking.
(A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III
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10/30/2023
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| Smoking.
(C) The contents of ashtrays shall be disposed of properly in receptacles made of noncombustible material. II/III
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10/30/2023
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| The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III
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10/30/2023
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