| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Drills and Emergency Preparedness.
(B) The plan shall include, but is not limited to, the following:
1. A phased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency;
2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building;
4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks;
5. Procedures for the safety and comfort of residents evacuated;
6. Staffing assignments;
7. Instructions for staff to call the fire department or other outside emergency services;
8. Instructions for staff to call alternative resource(s) for housing residents, if necessary;
9. Administrative staff responsibilities; and
10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III
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1/15/2026
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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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1/15/2026
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| Fire Safety Training Requirements.
(A) The facility shall ensure that fire safety training is provided to all employees:
1. During employee orientation;
2. At least every six (6) months; and
3. When training needs are identified as a result of fire drill evaluations. II/III
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1/15/2026
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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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1/15/2026
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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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1/15/2026
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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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1/15/2026
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