| 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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7/13/2022
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| Complete Fire Alarm Systems.
(A) All facilities shall have a complete fire alarm system installed in accordance with NFPA 101, Section 18.3.4, 2000 edition. The complete fire alarm shall automatically transmit to the fire department, dispatching agency, or central monitoring company. The complete fire alarm system shall include visual signals and audible alarms that can be heard throughout the building and a main panel that interconnects all alarm-activating devices and audible signals. Manual pull stations shall be installed at or near each required attendant ' s station and each required exit. I/II
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3/17/2022
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| Sprinkler Systems.
(B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II
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3/17/2022
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