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 — 123 tags
| Tag | What the surveyor checks | Facilities | Cited twice or more |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 9,716 | 4,979 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 7,521 | 3,030 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 6,395 | 2,147 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 6,084 | 1,928 |
| K-0363 | Install corridor and hallway doors that block smoke. | 6,019 | 2,208 |
| K-0324 | Provide properly protected cooking facilities. | 5,794 | 1,513 |
| K-0712 | Have simulated fire drills held at unexpected times. | 5,604 | 2,010 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 5,350 | 1,868 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 4,569 | 1,167 |
| K-0923 | Have proper medical gas storage and administration areas. | 4,244 | 827 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 4,219 | 1,226 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 4,152 | 907 |
| K-0222 | Add 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. | 4,100 | 991 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 3,801 | 785 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 3,767 | 817 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 3,281 | 609 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3,267 | 940 |
| K-0351 | Install an approved automatic sprinkler system. | 3,159 | 565 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 3,039 | 653 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2,648 | 406 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2,590 | 467 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2,544 | 369 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1,987 | 304 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1,739 | 361 |
| K-0161 | Use approved construction type or materials. | 1,723 | 410 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1,556 | 125 |
| K-0711 | Provide a written emergency evacuation plan. | 1,545 | 214 |
| K-0271 | Have exits that are accessible at all times. | 1,349 | 151 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1,290 | 137 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1,137 | 84 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1,040 | 136 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 959 | 198 |
| K-0281 | Install proper backup exit lighting. | 944 | 102 |
| K-0919 | Meet requirements for the use of electrical equipment. | 939 | 190 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 934 | 99 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 906 | 79 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 897 | 130 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 894 | 144 |
| K-0100 | Meet other general requirements. | 798 | 106 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 787 | 35 |
| K-0912 | Have power receptacles that are properly grounded. | 753 | 66 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 725 | 120 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 687 | 36 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 657 | 32 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 561 | 56 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 541 | 43 |
| K-0500 | Meet other general requirements that are deficient. | 530 | 49 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 502 | 62 |
| K-0331 | Construct fire resistant interior walls. | 476 | 27 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 468 | 105 |
| K-0300 | Meet other general requirements that are deficient. | 410 | 55 |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | 403 | 16 |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | 390 | 16 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 384 | 42 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 357 | 28 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 349 | 32 |
| K-0344 | Have an alternate power supply for its alarm system. | 326 | 29 |
| K-0915 | Have proper power supply for life support equipment. | 324 | 48 |
| K-0200 | Meet other general requirements. | 297 | 12 |
| K-0133 | Install a two-hour-resistant firewall separation. | 275 | 55 |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | 257 | 13 |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | 244 | 9 |
| K-0754 | Provide properly sized and located linen or trash receptacles. | 241 | 22 |
| K-0522 | Have an externally vented heating system. | 221 | 8 |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | 198 | 24 |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | 176 | 12 |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | 175 | 5 |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | 173 | 7 |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | 159 | 9 |
| K-0751 | Have restrictions on the use of flammable curtains. | 135 | 4 |
| K-0364 | Install properly constructed windows in hallway walls or doors. | 122 | 1 |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | 120 | 8 |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | 117 | 4 |
| K-0932 | Meet other general requirements. | 110 | 4 |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | 107 | 12 |
| K-0900 | Meet Health Care Facilities Code mechanical requirements. | 107 | 4 |
| K-0917 | Ensure electrical receptacles or cover plates have distinctive color or marking. | 103 | 1 |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | 88 | 2 |
| K-0930 | Ensure proper storage of liquid oxygen. | 80 | 6 |
| K-0221 | Provide rooms that can be unlocked from inside without a key. | 75 | 0 |
| K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. | 72 | 5 |
| K-0241 | Have correct number of accessible exits for each story. | 54 | 29 |
| K-0913 | Ensure operating rooms are properly protected and written records are maintained and available for inspection. | 53 | 1 |
| K-0163 | Install noncombustible or limited-combustible interior walls. | 47 | 3 |
| K-0233 | Install resident room doors of proper design and width. | 47 | 7 |
| K-0791 | Ensure 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. | 47 | 2 |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | 47 | 18 |
| K-0771 | Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | 47 | 2 |
| K-0224 | Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. | 41 | 1 |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | 35 | 0 |
| K-0231 | Provide large enough exits. | 33 | 0 |
| K-0902 | Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | 30 | 1 |
| K-0379 | Have proper openings in smoke barrier doors. | 28 | 0 |
| K-0251 | Conform to length requirements for dead end corridors. | 27 | 1 |
| K-0909 | Ensure gas and vacuum piping is labeled. | 27 | 3 |
| K-0255 | Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | 21 | 0 |
| K-0524 | Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | 19 | 1 |
| K-0525 | Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | 18 | 1 |
| K-0906 | Ensure gas cylinders are properly stored. | 17 | 0 |
| K-0904 | Have a properly installed medical gas master alarm panel. | 17 | 0 |
| K-0400 | Meet fire sprinkler requirement for tall buildings. | 16 | 0 |
| K-0532 | Have a properly installed and maintained dumbwaiter or escalator. | 16 | 0 |
| K-0523 | Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | 14 | 0 |
| K-0905 | Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | 13 | 0 |
| K-0254 | Provide hallway or ground-level exits in all residents' rooms. | 13 | 2 |
| K-0373 | Have enough space near smoke barriers to protect residents. | 12 | 1 |
| K-0924 | Ensure that anesthesia apparatus are tested after any adjustment, modification or repair. | 11 | 0 |
| K-0162 | Have a combustible roofing system that meets safety standards. | 11 | 0 |
| K-0261 | Have properly spaced exits within rooms. | 9 | 2 |
| K-0253 | Provide two separate exits in rooms of more than 1000 square feet. | 5 | 1 |
| K-0381 | Provide outside doors or windows in every resident room. | 3 | 0 |
| K-0112 | Add automatic sprinklers after major renovation. | 3 | 0 |
| K-0933 | Ensure that periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. | 2 | 0 |
| K-0752 | Ensure new upholstered furniture and mattresses meet char length and heat release criteria. | 2 | 0 |
| K-0910 | Ensure when modifications are made that breach pipelines, testing is conducted on downstream portions of the piping system. | 2 | 0 |
| K-0903 | Ensure medical gas and air supply systems in which failure is likely to cause major injury or death, are correctly designated. | 1 | 0 |
| K-0322 | Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system. | 1 | 0 |
| K-0931 | Have a properly constructed or installed hyperbaric treatment facility. | 1 | 0 |
| K-0130 | Have other fire safety features required by fire safety codes. | 1 | 0 |
| K-0038 | Exits that are accessible at all times. | 1 | 0 |
| K-0025 | Walls that prevent smoke from passing through and would resist fire for at least one hour. | 1 | 0 |
| K-0072 | Exits that are free from obstructions and can be used at all times. | 1 | 0 |
| K-0257 | Ensure that non-sleeping suites have required exit access. | 1 | 0 |
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.
| Tag | What the surveyor checks | Facilities | Cited twice or more |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 2,835 | 567 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2,077 | 230 |
| E-0041 | Implement emergency and standby power systems. | 1,468 | 249 |
| E-0015 | Address subsistence needs for staff and patients. | 1,301 | 203 |
| E-0037 | Establish staff and initial training requirements. | 1,289 | 194 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1,101 | 98 |
| E-0030 | List the names and contact information of those in the facility. | 855 | 76 |
| E-0036 | Establish emergency prep training and testing. | 799 | 65 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 756 | 56 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 668 | 46 |
| E-0031 | Provide emergency officials' contact information. | 656 | 48 |
| E-0007 | Address patient/client population and determine types of services needed. | 590 | 44 |
| E-0025 | Create arrangements with other facilities to receive patients. | 526 | 27 |
| E-0024 | Establish policies and procedures for volunteers. | 503 | 32 |
| E-0029 | Develop a communication plan. | 494 | 33 |
| E-0020 | Establish policies and procedures including evacuation. | 477 | 43 |
| E-0032 | Provide primary/alternate means for communication. | 470 | 32 |
| E-0035 | Provide family notifications of emergency plan. | 449 | 29 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 432 | 27 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 413 | 41 |
| E-0023 | Establish policies and procedures for medical documentation. | 316 | 24 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 306 | 15 |
| E-0022 | Establish policies and procedures for sheltering. | 293 | 20 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 200 | 9 |
| E-0033 | Establish methods for sharing information. | 195 | 11 |
| E-0042 | Meet the requirements of an integrated health system. | 43 | 1 |