Top 10 Fire & Life Safety Citations in Senior Living to Help Prep for Your Next Survey

With so many areas to focus on within compliance, you’re probably wondering where to start or where to really focus improvements on.

With that in mind, we’re taking a look at the top 10 common fire and life safety citations at senior living organizations today, to give you a look into what inspectors are specifically watching out for. 

Read through the list to get a head start on areas to look out for and ways technology can help you stay ahead. 

(Data pulled from 2021 CMS report)

1. K353 -Sprinkler System – Maintenance and Testing

What is covered: The inspecting, testing and maintenance of automatic sprinkler and standpipe systems, in accordance with NFPA 25.

Common problems:

• Sprinkler heads (damaged, painted, mixed type, obstructed)
• Missed or overdue inspections or not recorded
• Lack of replacement parts/tools (heads and wrenches)
• Gauges past due for calibration

2. K321 – Hazardous Areas – Enclosure

What is covered: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with ¾ hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9.

Common problems:

• Non-self-closing or automatic-closing doors
• Placement of protective plates on doors

• No approved fire extinguisher system nearby

3. K363 –Corridor – Doors

What is covered: Corridor and hallway doors must be built to block smoke. Specifically, doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas resist the passage of smoke and are made of 1¾ inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke.

Common problems:

• Too much clearance underneath door (more than 1 inch)

• Doors without a proper latch (roller latches are prohibited)
• Obstructions, such as door stops 

4. K918 –Electrical Systems – Essential Electrical System Maintenance and Testing

What is covered: The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.

Common problems:

• Power switching is too slow
• Monthly tests not done or recorded
• Generator not being tested weekly

5. K920 –Electrical Equipment – Power Cords and Extension Cords

What is covered: Ensure proper usage of power strips and extension cords. Specifically, power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE.

Common problems:

• Extension cords used as a substitute for fixed wiring
• Power cords that are being used near residents are linked together, covered up with rugs or have multiple appliances plugged in

6. K372 –Subdivision of Building Spaces – Smoke Barrier Construction

What is covered: Ensure smoke barriers are constructed to a 1/2-hour fire resistance rating.

Common problems:

• Improper closures in ceilings
• Door inspections not recorded

7. K712 –Fire Drills

What is covered: Have simulated fire drills held at expected and unexpected times under varying conditions. Fire drills must include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Common problems:

• Missing documentation
• Failing to use different scenarios

8. K345 –Fire Alarm System – Testing and Maintenance

What is covered: Have approved installation, maintenance and testing program for fire alarm systems, in accordance with NFPA 70 and 72.

Common problems:

• Missed documentation of maintenance and testing
• Missed test on the right frequency

9. K324 –Cooking Facilities

What is covered: Provide properly protected cooking facilities, in accordance with NFPA 96.

Common problems:

• Small appliances used for more than limited cooking or food warming
• Failure to comply with corridor/smoke requirement

10. K211 –Means of Egress – General

What is covered: Keep aisles, corridors, passageways, accesses and exits free of obstruction in case of emergency.

Common problems:

• Leaving boxes or other objects in front of doors
• Storage blocking exits or pathways 

Overall best practices for fire and life safety compliance

• Ensure that your staff has a reminder system with a “how to” list so that they know what to look for in accordance with fire safety requirements

• Create mock life safety survey inspections
• Perform quarterly audits
• Keep a secondary copy of all your forms and handbooks, either in hard copy or in software

How a CMMS can help

For example, a CMMS like TheWorxHub helps you manage:

• Regular inspections and survey prep
• Quality audits
• Automated preventive maintenance (PM) tasks
• Inventory to prevent falling below on supplies

• And more

Let us help you simplify staying compliant at your senior living organization with our easy-to-use software.

Sources:

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms2786R.pdf