| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Range Hood Extinguishing Systems.
(B) In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000:
1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and
2. The extinguishing system shall be installed, tested, and maintained in accordance with NFPA 96, 1998 edition. II/III
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12/9/2019
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| 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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12/9/2019
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| Complete Fire Alarm Systems.
(C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II
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12/9/2019
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| Complete Fire Alarm Systems.
(D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II
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12/9/2019
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| Protection from Hazards.
(I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall 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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12/9/2019
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| Trash and Rubbish Disposal.
(A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II
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12/9/2019
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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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12/9/2019
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