Life Safety and Construction Documentation

Alcohol Based Hand Rub Dispenser (ABHR)

Alcohol Based Hand Rub Dispensers (ABHR) are protected in accordance with 8.7.3.1, unless all conditions are met:

1. Corridor is at least 6 feet wide
2. Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid a11d 18 ounces of Level l aerosols
3. Dispensers shall have a minimum of 4-foot horizontal spacing
4. Not more than an aggregate of l O gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
5. Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
6. Dispensers are not installed within l inch of a11 ignition source
7. Dispensers over carpeted floors are in sprinklered smoke compartments
8. ABHR does not exceed 95 percent alcohol
9. Operation of the dispenser shall comply with the following criteria:
10. The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
11. Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
12. An object placed within the activation zone and left in place shall not cause more than one activation.
13. The dispenser shall not dispense more solution than the aniount required for hand hygiene consistent with label instructions.
14. The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
15. The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed.
     

ABT-JR is protected against inappropriate access

Special consideration should be given to the following:

1. Obstructions created by the installation of hand-rub solution dispensers
2. Location of dispensers with regard to adjacent combustible materials and potential sources of ignition, especially where dispensers are mounted on walls of combustible construction
3. Requirements for other fire protection features, including complete automatic sprinkler protection, to be installed throughout the compartment
4. Amount and location of the flammable solutions, both in use and in storage, particularly with respect to potential for leakage or failure of the dispenser

Emergency Preparedness Plan and Training Records 

(Located in separate binder in the Safety Training Director Office.)

Fire Plan

Evacuation
Evacuation Plan in Case of Fire 
Evacuated Zone where fire is to another Zone

1.    Evacuation of an area is necessary in the presence of visible smoke/flame
2.    Person in Charge gives order for evacuation of building if needed.
3.    Residents are moved to a safe area as designated by the Person in Charge
4.    Begin by moving residents to opposite side of fire doors, using most efficient means
       available.
5.    When evacuating residents, go to safest zone as determined by person in charge
6.    Personnel from the employee pool at the Nurses Station will be assigned to assist in
       evacuating residents
7.    The Person in Charge shall leave the building only after a thorough inspection of the
       resident area, to ensure that all residents and staff members have been evacuated; also secured the safety of the resident's records
8.    The Person in Charge will ensure that all staff members have been accounted for and/or evacuated, and is responsible for counting residents, according          to midnight census sheet and staff.

Note: If building evacuation is necessary, refer to Disaster Plan

Fire Watch Policy

Fire Alarm System Out of Service

In the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period, the facility will do the following until the alarm system has been returned to service.

1. Notify Administrator/Administrative Person on Call and Maintenance immediately. They will notify the Fire Safety Division of the State Health Department at first working hours. Telephone Number 701-328-4873
2. Assign personnel without other duties to monitor the facility for any fire that may occur.
3. Complete the form for the fire watch
   1. Document the time of the round
   2. Initial each round
4. Make rounds hourly, checking all areas noted on the Fire Watch Form
5. If a fire is found, follow steps in the Fire Plan.

Automatic Sprinkler System Out of Service

In the event that the automatic sprinkler system is out of service for more than 10 hours in a 24-hour period, the facility will do the following until the system has been returned to service.

1. Notify Administrator/Administrative Person on Call and Maintenance immediately. They will notify the Fire Safety Division of the State Health Department at first working hours. Telephone Number 701-328-4873
2. Assign personnel without other duties to monitor the facility for any fire that may occur.
3. Complete the form for the fire watch
4. Document the time of the round
   1. Initial each round
5. Make rounds hourly, checking all areas noted on the Fire Watch Form
6. If a fire is found, follow steps in the Fire Plan.

Risk Assessments

(For new or remodeled construction only)

Sample Smoking Policy

Purpose:

Name of facility shall establish and maintain safe resident smoking practices.

Guidelines:

1. Designated smoking area: Main area out front of building, 20 feet away from entrance, by smoking receptacle but not in the parking lot. The resident must be there before they light up.
2. Smoking hours will be 9am to 8 pm with 2hr intervals between outings. This goes for when on outings.
3. All residents that smoke will be assessed for safe smoking practices by Social Services and be educated on the smoking assessment/agreement and guidelines of smoking policy for the facility.
4. The weather guidelines must be observed by all residents and staff assisting residents for their safety. The following are the weather-related guidelines:
   1. 15 degrees and above with moderate wind is allowable for normal outdoor smoking (maximum of 2 cigarettes).
   2. 1-15 degrees is allowable for ONE cigarette only.
   3. When O degrees and below, there will be NO SMOKING OUTDOORS due to the safety risks associated with hypothermia and frost bite.
5. All residents must be dressed appropriately for weather and an easy read thermometer at the Nurse's station will determine the outdoor temperature or the nurse's cell phone weather app. If there is any dispute or malfunction of the thermometer or the weather conditions are other than stated above and there is reasonable cause to not allow outdoor smoking, the charge nurse must use discretion and reason to determine risk and allow/not allow outdoor smoking and document the reason in the resident chart.
6. Residents must "check-out and check-in" for smoking materials with designated staff and the designated staff must follow up with the resident if they have not been checked back in 15 minutes after checking out.
7. Residents who needs a smoking apron per their assessment/agreement, must have it on.
8. Residents are encouraged to have a cell phone with Care Center number preprogrammed into the phone when outside and be able to demonstrate ability to call with phone. An door bell alarm has been installed on the bench for residents use in case of an emergency when our smoking. There is also a camera installed to view the front entry way at the nurses station.
9. Resident's room may be subject to room searches if reasonable suspicion that a resident has been smoking in facility.
10. There may be warnings and the possibility of losing smoking privileges for non-compliance with the policy. 
11. Smoking materials found in the resident's room will be removed immediately.
12. Doors lock at 10 pm. All smoking for the day will be done at that time.
13. Residents are not to share smoking materials with others.
14. If resident breaks the rules (smoking around oxygen; giving smoking materials to other residents; throwing butts on the ground; lighting cigarettes prior to reaching the designated area; or other assessment or policy guidelines, etc.) they will be reassessed. If it was a violation that put others at risk (smoking in bathroom or resident room; smoking around oxygen; not properly disposing of materials; etc) they lose privileges to smoke and are given option to use ND Quit (like gum, medications, patches to cease smoking).
15. Non-compliance will result in being asked to find another long-term care facility.
    1. Resident will be consulted on smoking policy if caught smoking.
    2. Smoking materials found in resident's room will be removed immediately and "smoking" policy reviewed. Smoking cessation will be offered again.
    3. Resident who continues to smoke will be given 30-day notice to find a replacement facility.
16. New admission will not be allowed to smoke and will not be evaluated for smoking privileges.
17.  lf for any reason the resident leaves the facility and does not do a bed hold and then returns for admission, the resident would be considered as a new admission and would not qualify for grandfathering into the evaluation/agreement smoking policy.
    
     

Date Implemented:                       Date Reviewed/Revised              Reviewd/Revised By:

Automatic Sprinkler System Records

As-built system installation drawings, hydraulic calculations, original acceptance test records, and device manufacturer's data sheets shall be retained for the life of the system.

Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.

Battery Pack Emergency Lighting Records

Records shall be retained until the next test and for 1 year thereafter.

Cubicle Curtains and Draperies Documentation

Documentation shall be retained for the duration of the item in the facility.

Fire Alarm and Smoke Detectors Records

Fire Alarm system records shall be retained until the next test and for 1 year thereafter.

Smoke Detector sensitivity shall be checked within 1 year after installation. Sensitivity shall be checked every alternate year thereafter unless after the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range, the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Semi-Annual Fire Alarm Battery Load Voltage Test

Example: Fire Alarm Inspection Report

Page 1:

SimplexGrinnell

FIRE ALARM INSPECTION REPORT

Performed in Accordance with Applicable National Fire Protection Association Standards

Inspection
PREPARED FOR
Facility

SimplexGrinnell

Page 2:

SimplexGrinnell

FIRE ALARM INSPECTION REPORT SITE: Facility

TABLE OF CONTENTS

Test Summary 1

Monitoring/Jurisdictional Agencies 2

Test Results - Control Panel/Central Processing Unit 3

Test Results - Alarm Initiating Devices 5

Test Results - Alarm Indicating Devices 8

Test Results - Control/Auxiliary Devices 11

Sensitivity Test Results 12

Inspection Deficiency Summary 14

Inspection Deficiencies 15
 

Image: Sample Fire Alarm Inspection Report

 

Fire Dampers Records 

Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 

All documentation shall be maintained and made available for review by the AHJ. 

Name of Facility:

Fire/Smoke Damper Test

Fire Door Inspection Records

Periodic inspections and testing shall be performed not less than annually. Records shall be retained for a period of at least 3 years.

What to look for during a door inspection

1. Is the door and frame free from holes and breaks in all surfaces?
2. Are all the glazing, vision light frames and glazing beads intact and securely fastened?
3. Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage?
4. Is the door free from missing or broken parts?
5. Is the clearance from the door edge to the frame no more than 1/8 inch?
6. Is the door undercut no more than¾ inch?
7. Does the active door leaf completely close when operated from the full open position?
8. Does the inactive·leaf close before the active leaf when a coordinator is used?
9. Does the latching hardware operate and secure the door in the closed position?
10. Is the door assembly free from any auxiliary hardware items which could interfere with its operation?
11. Is the door free from any modifications since it was originally installed?
12. If gasketing and edge seals are installed, have they been verified for integrity and operation?
13. Is 95% of the surface of the door free from signage?

Image:  Sample floor plan with Fire Door Locations

Annual Fire Door Inspection

Fire Drill Records - 1 per shift per quarter

Records shall be retained until the next drill and for 1 year thereafter.
 

Healthcare Fire Drill Tracking

Basic Care Fire Drill Tracking

Fire Drill Report
Image:  Sample of a completed Fire Drill Report

Floor Finish Documentation - New only 

Documentation shall be retained for the duration of the product in the facility.

Image:  Example of flooring product and safety specifications Page 1 of 2.

Image shows the following specifications:
ASTM E648 - Critical Radiant Flux (Radiant Panel): Passes Requirements for Class I per International Building Code (IBC) 2018 & NFPA 101 Life Safety Code.
2 ASTM E662 - Smoke Density: 450 is the limit established by many state, county, and/or local building and/or fire codes, but is not set as a limit for (resilient) flooring products
nationwide. Thus, Smoke Density requirements for flooring products may vary from jurisdiction to jurisdiction. Consult your building inspector / fire marshal to learn more.
3 CPSIA = Consumer Product Safety Improvement Act.
4 Product tested uninstalled.

Image:  Example of flooring product and safety specifications Page 2 of 2.

Furnishings and Mattresses Documentation

Documentation shall be retained for the duration of the item in the facility.

Example of documentation:

Direct Supply
Simple Sleep
Foam Mattress

Owner's Manual

Thank you for purchasing a Simple Sleep Foam Mattress. Please read this entire manual carefully and keep it for future reference. This manual will provide you with instructions, warnings, warranty information and other important information about your mattress. Share this information with individuals who will be assembling, using, servicing and/or cleaning the product to help ensure it is cared for properly. 

Product Specifications

Cover: 
Two-way stretch top cover with backing 

Heavy-duty, nonskid bottom cover 

Antimicrobial, breathable, fluid-resistant, low-shear. tear-resistant, ¾ concealed zipper 

Fire Ratings: 
16 CFR 1633, 16 CFR 1632 

Weight Capacity
                                                                            Weight Capacity                  Weight                       
Product Part                                                            (lbs.)                           Capacity (kg)
Direct Supply Simple Sleep Foam Mattress            300 lbs                              36kg

 

Directions for Use

1. To ensure full mattress expansion, the mattress must be unpackaged within 48 hours of receipt. Do not use razor blades to cut packaging away from mattress.
2. Unpack the mattress in an area with sufficient room to work. Do not allow children, animals or individuals with impaired cognitive or physical abilities near the product until it has been completely set up and the work area has been cleared of all debris.
3. Inspect the mattress for shipping damage. If the mattress is damaged, DO NOT USE MATTRESS and immediately contact the distributor for further instruction.
4. Verify the proper mattress model and size was shipped. If you feel there was a mistake. DO NOT USE MATTRESS and immediately contact the distributor.
5. After verifying you've received the correct product without damage, properly discard all shipping materials.
6. Place the mattress on the bed frame and secure as necessary.
7. Compressed mattresses need time to properly recover. Allow the mattress to recover for 24 hours before using.
8. After 24 hours, the mattress is ready to use. If after 24 hours the mattress does not appear to have properly recovered. DO NOT USE MATTRESS and immediately contact the distributor.

NOTE: Do not remove product tag, cleaning instruction tag or law tag from the mattress. Removal of tags will void the warranty. 

NOTE: Always make sure the "Foot End" label of the mattress is positioned at the foot end of the bed. 

Generator and Transfer Switch Records
A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

Example of Emergency Generator Weekly Inspection Checklist.
 

Any Town Nursing Home
Emergency Generator - Weekly Inspection Checklist
 

Example: Emergency Generator Monthly Test Log

Any Town Nursing Home
Emergency Generator – Monthly Test Log

Generator Model:  Caterpillar                           Engine Model:  C18                                                                          Date Installed:  July 21, 2023
Standby kW nameplate rating: 600 kW              30% of standby rating = 180 kW           Fuel type: Diesel             Normal operating temp: 180° to 200° F

Image: Example of a Planned Maintenance Checklist Page 1.

Example of Planned Maintenance Checklist Page 2

Diesel Generator Load Calculation (NFPA 110) 

Amps: L1 ___ + L2 ___ + L3 ___ = Amps / 3 = ___ Avg Amps

Avg Amps:___x Volts:____x 1.732 (for 3ph) / 1000 = ____ Load KW

Load KW:____ / Name Plate KW:____=____% of Name Plate KW

If final KW calculation is greater than 30% of name plate value = "Pass" 
If final KW calculation is less than 30% of name plate value = "Fail"

Example of Diesel Generator Load Calculation:

Amps: L1 50 + L2 49 + L3 51 = Amps / 3 = 50 Avg Amps

Avg Amps: 50 x Volts 480 x 1.732 (for 3ph) / 1000 = 41 Load KW

Load KW: 41 / Name Plate KW: 250 = 16 % of Name Plate KW

If final KW calculation is greater than 30% of name plate value = "Pass" 
If final KW calculation is less than 30% of name plate value = "Fail"

Note: 1 Kiloampere = 1000 Amps

Image:  Example of Load Bank Test Data Form

Comments:

Interior Finish Documentation:

• Inspection:
  • Hoods shall be inspected monthly with date noted on log sheet.
  • Semiannually – maintenance and inspection for cleaning shall be conducted.
• Records:
  • Documentation shall be retained for the duration of the product in the facility.
• Product Information Sheet:
  • Floors
• Description
• Product Specifications
• Physical Properties
• Fire Hazard Classification:
  • Fire Rating: ASTM E-84 or ANSI/UL 723
    • Flame Spread: 25
    • Smoke Developed: 20
• Walls
  • Description
  • Product Specifications
  • Physical Properties
  • Fire Hazard Classification:
    • Fire Rating: See Chapter 10, Table 10.2 of NFPA 101 for the appropriate test method which will define the Flame Spread and Smoke Developed standards.

Interior Finish Documentation
Documentation shall be retained for the duration of the product in the facility

Image:  Example Commercial Wallpaper Specifications

Portable Fire Extinguishers Records 

Where monthly manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist. 

Fire extinguishers inspected via electronic monitoring, whereby the extinguisher causes a signal at a control unit when a deficiency occurs, shall provide record keeping in the form of an electronic event log at the control panel. Where electronically monitored systems are employed for inspections, records shall be kept for fire extinguishers found to require corrective action. 

Records shall be kept demonstrating that at least the last 12 monthly inspections have been performed. 

Image:  Example of a Facility floor plan with Fire Extinguisher locations.


Example:  Monthly Fire Extinguisher Inspection Log

Monthly Fire Extinguisher Inspections
January 2026

Range Hood System Records

At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. Records shall be retained for the period between the semiannual maintenance inspections. 

At least semiannually, maintenance and inspection for cleaning shall be conducted. Records shall be retained for a period of 1 year after the next required maintenance and inspection for cleaning.

Example: Monthly Range Hood Extinguishing System Inspections
 

Image:  Example of a Wet Agent Fires Suppression System Inspection and Testing Report Page 1.

Image:  Example of a Wet Agent Fires Suppression System Inspection and Testing Report Page 2

Image: Example of Inspection and Cleaning of Kitchen Exhaust Sytems.

Range Hood Systems

• Inspection of UL300 Kitchen Range Hood:
  • Monthly - Hoods shall be inspected per manufacturer’s listed installation and maintenance manual or the owner’s manual.
  • Semiannually – The range hoods automatic extinguishing system must be serviced and inspected for cleaning.
• Records:
  • The date of the inspection and the initials of the inspector shall be kept on record.
  • Monthly Records shall be retained for the period between the semiannual maintenance inspections.
  • Semiannual Records shall be retained for a period of 1 year after the next required maintenance and inspection for cleaning.
• Inspection Sheets: These are usually provided by the company doing the inspection.
  • Wet Agent Fire Suppression System Inspection and Testing Report.
    • Work Site #
    • Name of facility
    • Street Address
    • City – State and zip code
    • Authority Contact and phone number
    • Date – Time in and time out
    • Last maintenance date and performed the maintenance
    • Manufacturer
    • Type of Wet Agent
    • Control/Release Data
    • Expellant Gas Line
    • Tank/Cylinder Data
    • Nozzles
    • Detection Data
    • Remote Release Data
    • Gas Valve Data
    • Electrical Functions
    • Notification/Annunciation
•  Inspection and Cleaning of Kitchen Exhaust Systems
• The extinguishing system is in its proper location.
• The manual actuators are unobstructed.
• The tamper indicators and seals are intact.
• The maintenance tag or certificate is in place.
• No obvious physical damage or condition exists that might prevent operation.
• The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
• The nozzle blow-off caps, where provided, are intact and undamaged.
• Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.
• If any deficiencies are found, appropriate corrective action shall be taken immediately. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections.
• A K-type fire extinguisher is required in kitchens that are equipped with a UL 300 hood system. A sign must be installed instructing on the use of the extinguisher.