| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Drills and Emergency Preparedness.
(F) The fire alarm shall be activated during all fire drills unless the drill is conducted between 9 p.m. and 6 a.m., when a facility-generated predetermined message is acceptable in lieu of the audible and visual components of the fire alarm. II/III
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6/24/2021
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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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6/24/2021
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