| 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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7/11/2023
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| 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
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7/11/2023
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| 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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7/11/2023
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| Emergency Lighting.
(A) Emergency lighting of sufficient intensity shall be provided for exits, stairs, resident corridors, and required attendants ' station. II
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7/11/2023
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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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7/11/2023
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