Understanding the citation codes CMS surveyors use to document physical environment deficiencies in healthcare facilities.
K-tags are the citation codes CMS surveyors use to document physical environment deficiencies during Life Safety Code surveys. Understanding them is the first step toward preventing them.
K-tags (K0001 through K0933) are the specific regulatory tags CMS uses to categorize Life Safety Code deficiencies found during healthcare facility surveys. Each K-tag maps to a specific requirement from NFPA 101 or related fire protection standards.
When a surveyor identifies a physical environment deficiency, they cite it using the corresponding K-tag number. These citations appear on your facility's CMS survey report and can impact star ratings, trigger follow-up surveys, and in severe cases, lead to Immediate Jeopardy determinations.
HIGH FREQUENCY
Automatic sprinkler systems must be installed and maintained per NFPA 13. Covers coverage gaps, obstructions, head spacing, and system integrity.
Fire alarm systems must be maintained per NFPA 72. Includes testing schedules, device functionality, and documentation requirements.
Hazardous areas must be properly separated by smoke-resistant barriers or protected by automatic sprinklers. Common in storage, laundry, and mechanical rooms.
Electrical wiring and equipment must comply with NFPA 70 (National Electrical Code). Covers outlets, panels, grounding, and extension cord misuse.
Means of egress must be continuously maintained free of obstructions. Covers blocked exits, locked doors, and path-of-travel issues.
Portable fire extinguishers must be provided, maintained, and inspected per NFPA 10. Covers placement, accessibility, inspection tags, and annual maintenance.
Fire drills must be conducted quarterly on each shift. Documentation must include date, time, staff participation, simulated conditions, and evaluation notes.
Smoke barriers must maintain integrity. Covers penetrations, door gaps, above-ceiling continuity, and damper functionality.
SEVERITY
Every deficiency is rated on two dimensions: severity (how much harm) and scope (how widespread). This section covers severity; scope follows below.
NO ACTUAL HARM
No actual harm, with potential for only minimal harm.
NO ACTUAL HARM
No actual harm, with potential for more than minimal harm (not immediate jeopardy).
ACTUAL HARM
Actual harm to residents that is not immediate jeopardy.
IMMEDIATE JEOPARDY
Immediate jeopardy to resident health or safety. Serious injury, impairment, or death is likely.
SCOPE
Severity is only half the story. Every deficiency is also classified by scope — how broadly the problem extends across the facility.
Affects one or a very limited number of residents or locations within the facility.
Affects more than a limited number of residents or locations, but the locations are not dispersed facility-wide.
Pervasive or systemic. Affects, or could affect, a large portion or all of the facility’s residents.
Each deficiency is graded on both dimensions. A Level 1 deficiency can still be Widespread, and an Isolated finding can still be Immediate Jeopardy.
| Severity \ Scope | Isolated | Pattern | Widespread |
|---|---|---|---|
| Level 4 — Immediate Jeopardy | J | K | L |
| Level 3 — Actual Harm | G | H | I |
| Level 2 — Potential for More Than Minimal Harm | D | E | F |
| Level 1 — Potential for Minimal Harm | A | B | C |
Letters A–L are the CMS scope/severity grid designations used on the Form CMS-2567 statement of deficiencies.
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