| 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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7/26/2023
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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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7/26/2023
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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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7/26/2023
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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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7/26/2023
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