Life Safety Index

Citation tags

Surveyors record findings as numbered tags. Nursing homes receive two sets, published together but drawn from different rules: K-tags come from the Life Safety Code, and E-tags from the Emergency Preparedness requirements at 42 CFR §483.73.

Life Safety Code — 120 tags

Life Safety Code tags cited at US nursing homes
TagWhat the surveyor checksFacilitiesCited twice or more
K-0353Inspect, test, and maintain automatic sprinkler systems.9,7655,024
K-0918Have generator or other power source capable of supplying service within 10 seconds.7,5593,049
K-0345Have approved installation, maintenance and testing program for fire alarm systems.6,4702,197
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.6,0681,925
K-0363Install corridor and hallway doors that block smoke.6,0552,198
K-0324Provide properly protected cooking facilities.5,8431,560
K-0712Have simulated fire drills held at unexpected times.5,6372,044
K-0920Ensure proper usage of power strips and extension cords.5,3441,857
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.4,5761,181
K-0923Have proper medical gas storage and administration areas.4,257829
K-0511Have properly installed electrical wiring and gas equipment.4,2491,261
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.4,129907
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.4,107962
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.3,804791
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.3,757822
K-0291Install emergency lighting that can last at least 1 1/2 hours.3,272596
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.3,231941
K-0351Install an approved automatic sprinkler system.3,141568
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.3,029649
K-0293Have properly located and lighted "Exit" signs.2,660416
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.2,586467
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.2,538365
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.1,987318
K-0921Ensure that testing and maintenance of electrical equipment is performed.1,758343
K-0161Use approved construction type or materials.1,719399
K-0341Install a fire alarm system that can be heard throughout the facility.1,546123
K-0711Provide a written emergency evacuation plan.1,545204
K-0271Have exits that are accessible at all times.1,339153
K-0911Meet requirements for the installation and maintenance of electrical systems.1,299135
K-0781Have restrictions on the use of portable space heaters.1,14277
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.1,023126
K-0281Install proper backup exit lighting.949104
K-0311Have an enclosure around a vertical opening shaft.937191
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.928105
K-0919Meet requirements for the use of electrical equipment.924194
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.89471
K-0347Properly provide smoke detection systems in areas open to corridors.893124
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.888144
K-0100Meet other general requirements.788110
K-0916Have a battery powered remote alarm panel in a location accessible by operating personnel.78133
K-0912Have power receptacles that are properly grounded.73366
K-0531Have elevators that firefighters can control in the event of a fire.730133
K-0753Have restrictions on the use of highly flammable decorations.69838
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.64832
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.56055
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.55049
K-0500Meet other general requirements that are deficient.54255
K-0926Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.48259
K-0541Install properly constructed and protected linen or trash chutes.481102
K-0331Construct fire resistant interior walls.45224
K-0300Meet other general requirements that are deficient.39855
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.39717
K-0352Properly install and monitor supervisory attachments on automatic sprinkler systems.39513
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.38442
K-0929Ensure precautions for handling oxygen cylinders and equipment are correctly followed.36226
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.35134
K-0915Have proper power supply for life support equipment.34148
K-0344Have an alternate power supply for its alarm system.32929
K-0200Meet other general requirements.29611
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.26113
K-0133Install a two-hour-resistant firewall separation.26156
K-0361Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.24310
K-0754Provide properly sized and located linen or trash receptacles.23723
K-0522Have an externally vented heating system.2138
K-0922Meet requirements for the use and maintenance of medical gas equipment.19621
K-0700Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.1805
K-0371Have properly sized and located compartments to protect residents from smoke.17012
K-0111Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.1647
K-0226Have horizontal exits used in accordance with safety requirements.1569
K-0751Have restrictions on the use of flammable curtains.1364
K-0364Install properly constructed windows in hallway walls or doors.1181
K-0908Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.1179
K-0932Meet other general requirements.1123
K-0132Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.10811
K-0925Ensure that sources of ignition are removed from patients receiving respiratory therapy.1075
K-0900Meet Health Care Facilities Code mechanical requirements.1064
K-0917Ensure electrical receptacles or cover plates have distinctive color or marking.1051
K-0227Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.822
K-0930Ensure proper storage of liquid oxygen.775
K-0221Provide rooms that can be unlocked from inside without a key.750
K-0907Ensure medical gas and vacuum systems have documented maintenance programs.734
K-0241Have correct number of accessible exits for each story.5625
K-0913Ensure operating rooms are properly protected and written records are maintained and available for inspection.491
K-0771Ensure that smoke control systems are tested and documented in accordance with established engineering principles.492
K-0791Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.491
K-0233Install resident room doors of proper design and width.487
K-0252Provide at least two remote exits on each floor or fire section of the building.4716
K-0224Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.441
K-0163Install noncombustible or limited-combustible interior walls.433
K-0928Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.400
K-0902Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.322
K-0231Provide large enough exits.290
K-0379Have proper openings in smoke barrier doors.280
K-0909Ensure gas and vacuum piping is labeled.282
K-0251Conform to length requirements for dead end corridors.261
K-0255Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.200
K-0525Enure that solid fuel-burning fireplaces are not in patient sleeping areas.181
K-0524Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.171
K-0906Ensure gas cylinders are properly stored.160
K-0532Have a properly installed and maintained dumbwaiter or escalator.161
K-0523Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.160
K-0400Meet fire sprinkler requirement for tall buildings.160
K-0904Have a properly installed medical gas master alarm panel.140
K-0373Have enough space near smoke barriers to protect residents.121
K-0254Provide hallway or ground-level exits in all residents' rooms.122
K-0905Ensure that gas containers are correctly designed and tested, and in locations that are labeled.110
K-0924Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.110
K-0162Have a combustible roofing system that meets safety standards.100
K-0261Have properly spaced exits within rooms.92
K-0253Provide two separate exits in rooms of more than 1000 square feet.51
K-0381Provide outside doors or windows in every resident room.40
K-0112Add automatic sprinklers after major renovation.30
K-0910Ensure when modifications are made that breach pipelines, testing is conducted on downstream portions of the piping system.20
K-0752Ensure new upholstered furniture and mattresses meet char length and heat release criteria.20
K-0322Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system.10
K-0038Exits that are accessible at all times.10
K-0933Ensure that periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established.10
K-0130Have other fire safety features required by fire safety codes.10
K-0025Walls that prevent smoke from passing through and would resist fire for at least one hour.10
K-0072Exits that are free from obstructions and can be used at all times.10

Emergency Preparedness — 26 tags

Cited at roughly half of all cited facilities, and mostly about plans, training and records rather than the building itself. They have their own index: the Emergency Preparedness Index.

Emergency Preparedness tags cited at US nursing homes
TagWhat the surveyor checksFacilitiesCited twice or more
E-0039Conduct testing and exercise requirements.2,836566
E-0004Develop and maintain an Emergency Preparedness Program (EP).2,051237
E-0041Implement emergency and standby power systems.1,413232
E-0015Address subsistence needs for staff and patients.1,272192
E-0037Establish staff and initial training requirements.1,269188
E-0006Conduct risk assessment and an All-Hazards approach.1,10492
E-0030List the names and contact information of those in the facility.85767
E-0036Establish emergency prep training and testing.78868
E-0026Establish roles under a Waiver declared by secretary.73854
E-0013Develop Emergency Preparedness policies and procedures.67344
E-0031Provide emergency officials' contact information.64247
E-0007Address patient/client population and determine types of services needed.57645
E-0025Create arrangements with other facilities to receive patients.53927
E-0029Develop a communication plan.48333
E-0024Establish policies and procedures for volunteers.48130
E-0020Establish policies and procedures including evacuation.48142
E-0032Provide primary/alternate means for communication.46635
E-0035Provide family notifications of emergency plan.42930
E-0009Include a process for Emergency Preparedness collaboration.42541
E-0018Establish procedures for tracking staff and patients during an emergency.42023
E-0023Establish policies and procedures for medical documentation.30424
E-0034Provide a means of sharing information on occupancy/needs.29515
E-0022Establish policies and procedures for sheltering.27919
E-0033Establish methods for sharing information.1909
E-0001Establish an Emergency Preparedness Program (EP).1837
E-0042Meet the requirements of an integrated health system.431