Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents 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 2/4/2025   
Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility ' s entire plan shall be provided to the local jurisdiction ' s emergency management director. II/III 2/4/2025   
Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. III 2/4/2025   
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 2/4/2025   
Exits, Stairways, and Fire Escapes. (G) All stairways and corridors shall be easily negotiable and shall be maintained free of obstructions. II 2/4/2025   
Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III 2/4/2025   
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 2/4/2025   
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 2/4/2025   
Complete Fire Alarm Systems. (H) When a complete fire alarm system is to be out-of- service for more than four (4) hours in a twenty-four- (24-) hour period, the facility shall immediately notify the department and the local fire authority and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the complete fire alarm system has returned to full service. I/II 2/4/2025   
Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility I or II, and existing prior to November 13, 1980, shall be exempt from this requirement. II 2/4/2025   
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 2/4/2025   
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 2/4/2025   
Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II 2/4/2025   
In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III 2/4/2025