| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Drills and Emergency Preparedness.
(B) The plan shall include, but is not limited to, the following:
1. A phased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency;
2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building;
4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks;
5. Procedures for the safety and comfort of residents evacuated;
6. Staffing assignments;
7. Instructions for staff to call the fire department or other outside emergency services;
8. Instructions for staff to call alternative resource(s) for housing residents, if necessary;
9. Administrative staff responsibilities; and
10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III
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8/24/2022
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| Sprinkler Systems.
(A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II
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8/24/2022
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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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8/24/2022
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