| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| 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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8/1/2023
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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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8/1/2023
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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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8/1/2023
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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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8/1/2023
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