Life safety code and emergency preparedness reviews can sometimes play second chair to a community’s area of focus when their skilled nursing facility or assisted living survey window is open. While ensuring the personal care and services provided to our residents are of the highest standard is paramount, the importance of having proper policies and procedures in place from a physical plant and emergency preparedness perspective cannot be overstated.

In fact, in September of 2023, Georgia’s Office of Inspector General (OIG) performed an unannounced audit of 20 nursing homes in Georgia that participated in Medicare and Medicaid and evaluated these facilities’ compliance with life safety and emergency preparedness.[1] The report concluded that 19 of the 20 nursing homes had a total of 155 deficiencies (71 related to life safety and 66 related to emergency preparedness).[2] The following deficiencies most often identified related to life safety and emergency preparedness included:

  • Building exits, fire barriers, and smoke partitions (29 deficiencies)
  • Fire detection and suppression systems (23 deficiencies)
  • Emergency communication plans (23 deficiencies)
  • Emergency preparedness plan training and testing (23 deficiencies)

It is of no surprise that many of the deficiencies cited throughout the Georgia OIG’s report are among the most observed issues HDG has noted when performing mock surveys for its clients. As such, HDG has developed a list of five areas of concern and what communities can do to prevent unnecessary deficiencies.

1.   Preventive Maintenance Records

As the old adage goes, “if it’s not documented, it didn’t happen.” While this is most certainly the golden rule when it comes to direct patient care, it is also essential for maintenance directors to ensure they (and their staff) are consistently and accurately logging all preventative maintenance tasks. Many communities are still paper-based when it comes to tracking fire drills, smoke detector inspections, fire extinguishers, emergency lighting, etc. Although this is a long-standing and acceptable method of recording keeping, it is essential that all data is compiled in a logical and consistent manner (i.e., consolidated into a smaller number of binders with the most current logs located at the front of each section).

Electronic databases, such as TELS, provide users with numerous capabilities for improved tracking of maintenance tasks and facility requests. These databases allow users to set recurring tasks (daily, monthly, annually, etc.) and report if any tasks are incomplete or past due. Maintenance personnel can also receive and close out any requests electronically, as opposed to using verbal or paper methods that can be forgotten or misplaced.

2.   Fire Doors and Automatic Closure Devices

As noted above, building exits, fire barriers, and smoke partitions were among the most frequently cited deficiencies in the Georgia OIG’s audit. Specifically, the OIG noted corridor doors that did not close properly, would not latch, or did not fully seal (which included self-closing doors). Improper functionality of fire doors allows smoke and fire to spread more quickly throughout a facility. A door with a 90-minute fire rating is not going to be effective for that length of time if it does not close properly.

Door stoppers are by far the most common culprits HDG has observed regarding this deficiency. Automatic fire doors with magnetic releases will be rendered ineffective if a fire alarm is triggered and negate any life saving measures it would have otherwise provided. Although it is not always a popular choice among staff and residents, best practice is to remove these devices from use and ensure fire doors are able to perform as intended.

3.   Interior Walls and Ceiling Finishes

Broken or missing ceiling tiles fall under the above fire barrier and smoke partition deficiency, but it also deserves its own section as it is one of the most observed issues, especially in older buildings. Water damage or alterations to ceiling tiles (e.g., holes drilled or cut for IT network cables or electrical cables) increase the spread of smoke and fire and can prevent smoke detectors or fire sprinklers from functioning properly in the event of a fire.









Source: HDG photograph of client community

Due to the hazard these penetrations pose, it is essential to replace ceiling tiles and properly seal any openings required for cabling. Firestop installations for groupings of multiple conduits or fire caulking for smaller conduit penetrations are required to effectively seal and maintain the smoke and fire barrier as intended.

4.   Fire Detection and Suppression Systems

Georgia’s OIG audit indicated a blocked or an obstructed sprinkler head was a deficiency in 12 of the 20 nursing homes visited.1 The most common occurrence of this deficiency is found in storage rooms. Boxes and other materials stacked too high to the ceiling become an issue when it prevents the sprinkler heads from providing sufficient suppression of fire during an event.[3] The 18-inch rule applies to areas with sprinkler systems installed, and a blockage is considered an obstruction if storage is any closer than this 18-inch minimum distance. The purpose of this rule is “to make sure the obstruction doesn’t block the development of the sprinkler pattern which occurs within the first 18 vertical inches (450 mm) of the sprinkler.”

A routine audit of a community’s sprinklered storage areas (as well as other locations) will help ensure that sprinklers will function in the manner intended and provide adequate suppression if a fire were to occur.

5.   Emergency Preparedness Plans

The complexities around the emergency preparedness plan could warrant an entire blog on its own, but two key areas addressed by the OIG report include the communication plan and training and testing.

Communication Plan

The communication plan is an essential part of the emergency preparedness plan and contains information such as staff contact numbers, resident physicians, alternate site contacts in cases of site evacuation, and other emergency service providers. As with the rest of the emergency preparedness plan, this component must be reviewed and updated annually to ensure all information is still current. Another critical component is establishing which method of communication will be used in disaster/emergency situations. For example, does your community use two-way radios or cellphone applications for all-staff communications? The primary and secondary means of communication need to be indicated in the plan, and more importantly, it needs to be the actual means of communication used throughout the community. If the plan states two-way radios and staff is using cellphones, surveyors will surely tag the community for noncompliance with its own plan.

Training and Testing

Another heavily cited deficiency with the emergency preparedness plan is annual training and testing. Initial training for staff should occur with every new hire. It’s important to ensure that all staff know where the emergency preparedness plan is kept (often times the front desk or staff breakroom) and what they are expected to do in a disaster or emergency situation. In addition, staff need to be trained on the emergency preparedness plan annually, and leadership needs to review and update the plan on a yearly basis as well. Lastly, it is necessary to inform residents and their families about the emergency plan and what steps will be taken if an emergency were to occur.

Testing goes hand-in-hand with training. Annual full-scale testing is required, but best practice should also include a second training exercise which can include another full-scale exercise, mock disaster drill, or tabletop exercise or workshop. The purpose of these exercises is to analyze the community’s response, document the results, and revise the emergency preparedness plan as needed.

The key to both training and testing brings us back to that old adage, “if it’s not documented, it didn’t happen.” The emergency preparedness plan is definitely no exception to this golden rule.


There are many facets to life safety and emergency preparedness, and the items listed above are only a few that surveyors will be on the lookout for during their inspection. And remember, safety inspections and emergency preparedness aren’t just annual tasks; it is up to everyone to ensure that any potential hazards are addressed and corrected.

Contact Health Dimensions Group

Health Dimensions Group® (HDG®) has nearly 25 years of senior living and care experience—owning, operating, and providing management and consulting services for a vast array of partners. If you find yourself struggling to maintain compliance or establish policies and procedures to improve your current situation—including life safety code and emergency preparedness planning—please reach out to HDG for a Positive Review and Evaluation Process (PREP) mock survey, in which a wide range of activities—including nursing, recreation and activities, staffing, administration, dietary and meal service, abuse prevention, medication administration management, infection prevention and control, and QAPI—are assessed in order to help reduce your facility’s risk for deficiencies.

We would welcome the opportunity to share more about our insights and capabilities. For more information, please contact us at or 763.537.5700.

[1] U.S. Department of Health & Human Services, Office of Inspector General. “Georgia Could Better Ensure That Nursing Homes Comply with Federal Requirements for Life Safety, Emergency, Preparedness, and Infection Control.”

[2] The report also noted 18 deficiencies related to infection control.

[3] NFPA. “NFPA 13: Suspended or Floor Mounted Vertical Obstructions.”