| 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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2/4/2025
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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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2/4/2025
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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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2/4/2025
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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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2/4/2025
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| Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III
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2/4/2025
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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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2/4/2025
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| In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II
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2/4/2025
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