| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Extinguishers.
(D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III
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10/28/2021
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| 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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10/28/2021
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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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10/28/2021
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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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10/28/2021
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| 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
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10/28/2021
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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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10/28/2021
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| Sprinkler Systems.
(G) When a sprinkler 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 implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the sprinkler system has been returned to full service. I/II
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10/28/2021
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| Trash and Rubbish Disposal.
(A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II
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10/28/2021
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ICF2 |
10/28/2021
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