10 Common Life Safety Citations

February 6, 2017 Josh Malbogat

The definition of insanity is doing the same thing over and over again and expecting a different result. If you review life safety code citations from the last few years – you might say we’re all crazy. 

Nobody likes surprises and yet many providers are hit with the same citations each year. Striving for a zero citation survey can be a difficult task, but the payoff in terms of safety for residents and staff and your reputation can be significant.

There are clear trends right in front of us, and providers want better records moving forward. To help you on your way, we’ve identified some of the most common life safety citations being issued today, as well as what you can do to prevent them in your facility.

 

K62 – Sprinkler System Maintenance: Testing and maintenance of automatic sprinkler systems

WHAT IT LOOKS FOR

The testing and maintenance of automatic sprinkler systems, making sure that you’re doing the tests for the system at the right frequency found in NFPA 25.

COMMON PROBLEMS

  • Sprinkler heads (damaged, painted, mixed type, obstructed)
  • Missed or overdue inspections (calibration of gauges, 5 years)
  • Lack of replacement parts/tools (heads and wrenches)
  • Gauges past due for calibration
  • Storage placement

KEY TAKEAWAY: Check to make sure you document your tests!

 

K147 – Electrical Wiring and Equipment: Electrical wiring must be in accordance with NFPA 70, National Electrical Code

WHAT IT LOOKS FOR

Electrical wiring to be in accordance with NFPA 70, National Electrical Code. The most common offenders are things like power strips, power cords, etc. being used in areas they’re not allowed to be in.

COMMON PROBLEMS

  • Power strips (used near residents, linked together, covered up with rugs or have multiple appliances plugged in)
  • Exposed wiring (missing light switch and outlet covers, missing junction box cover plates)

KEY TAKEAWAY: Check to make sure there isn’t exposed wiring or tangled cords.

 

K29 – Hazardous Areas Separated: Keep areas like solid linen, trash rooms and repair shops separated

WHAT IT LOOKS FOR

Keeping areas like solid linen, trash rooms, repair shops or any room that may potentially be hazardous separated. There need to be specific door types for separation, cleanliness and organization.

COMMON PROBLEMS

  • Self-closing doors that are obstructed (or not self-closing at all)
  • Usage of space changed and doors/closures are not adapted
  • Solid utility bins stored in non-hazardous rooms

KEY TAKEAWAY: Check to make sure there are no door stops or any other door props.

 

K18 – Construction of Doors:

Doors that protect corridor opening must be free of obstructions and gaps, and prevent smoke from passing through

WHAT IT LOOKS FOR

Making sure that the doors that protect corridor openings can prevent smoke. It’s not only the construction, but it’s also to ensure that there are no obstructions that could prevent it from closing.

COMMON PROBLEMS

  • Gaps in doors as they age/warp/shrink
  • Doors without a proper latch
  • Obstructions such as door stops

KEY TAKEAWAY: Check to make sure your automatic/self-closing doors are working properly.

 

K144 – Generator Inspection & Load Testing: 

Inspect all generators weekly and exercise under load for 30 minutes per month in accordance with NFPA 99, section 3.4.4.1

WHAT IT LOOKS FOR

Generators need to be inspected weekly and monthly. They must be tested under a load for 30 minutes in accordance with NFPA 99, section 3.4.4.1.

COMMON PROBLEMS

  • Missed inspection tests
  • Missed documentation
  • Incorrect timing of the tests

KEY TAKEAWAY: Check to make sure you have the proper documentation and state requirements.

 

K38 – Exit Accessible at All Times: 

Exits must be clear of obstructions and accessible for staff

WHAT IT LOOKS FOR

The ability to leave the building at all times if there is a problem or emergency. Make sure that exits are clear of obstructions and clear for both staff and residents.

COMMON PROBLEMS

  • Storage blocking exits or the pathway
  • Delayed egress devices or failure
  • Doors not clearly marked as an exit, such as camouflage doors

KEY TAKEAWAY: Check to make sure you aren’t blocking any exits at any time and that your doors are clearly marked as an exit.

 

K25 – Smoke Barriers (1/2 Hour Fire Rating): 

Smoke barrier walls must have a 1/2 hour FRR (1 hour FRR for new construction)

WHAT IT LOOKS FOR

Smoke barrier walls with the correct fire rating, depending on old or new construction (plus any additions, changes or retrofitting).

COMMON PROBLEMS

Improper closures in ceilings. If you do make a hole, make sure you still seal it.

KEY TAKEAWAY: Check to make sure there are no errors that occur after a building passes inspection during construction.

 

K50 – Fire Drills and Emergency Preparedness: 

Fire drills need to be conducted at a minimum of once per shift per quarter randomly

WHAT IT LOOKS FOR

The conduction of emergency drills at least once per shift per quarter at random.

COMMON PROBLEMS

  • Following the same routine every quarter
  • Missing documentation
  • Failing to use different scenarios

KEY TAKEAWAY: Check to make sure you are truly doing these drills at random. Following the same routine is not going to properly prepare you or your residents for an emergency.

 

K52 – Fire Alarm Testing and Maintenance: 

Test the fire alarm system per required NFPA frequencies (NFPA 72, tables 7-3.1, 7.32, 7-52.2)

WHAT IT LOOKS FOR

A fairly new K-tag, this one ensures that your fire alarm system is testing at the right frequencies per NFPA 72, tables 7-3.1, 7.32, 7-52.2.

COMMON PROBLEMS

  • Missed test on the right frequency
  • Missed documentation
  • Omitting something that is not done and not marked as N/A on the form – even if you don’t have it, you must write N/A

KEY TAKEAWAY: Check to make sure you are also testing off premises transmission equipment to outside emergency service providers.

 

K56 – Auto Sprinkle System of Approved Type: 

Sprinklers must be installed throughout the facility in accordance with NFPA 13

WHAT IT LOOKS FOR

Sprinklers must be installed throughout facility in accordance with NFPA 13.

COMMON PROBLEMS

  • Areas that were missed in construction (closets, storage, attics, etc.)
  • Improper installation (spacing, coverage area)
  • Obstructions (storage, ductwork, light fixtures)

KEY TAKEAWAY: Check to make sure no areas were missed during construction.

OVERALL BEST PRACTICES

  • Ensure that your staff has a reminder system with a “how to” list so that they know what to look for.
  • Create mock survey inspections.
  • Perform quarterly audits.
  • Keep a secondary copy of all your forms and handbooks, either in hard copy or in software.

REMEMBER: These regulations are designed to save lives. Strive to be one of the 20% of facilities that are deficiency free!

10 Common Life Safety Citations Infographic

Download and share our 10 Common Life Safety Citations Infographic or read about How Focusing on Maintenance Can Create a Safer Environment for Your Residents.

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