Non-compliance with Combustible Decoration Standards
Summary
The facility failed to comply with NFPA 101 standards regarding combustible decorations. During an observation on December 18, 2024, between 12:45 p.m. and 1:05 p.m., it was noted that the facility had posters covering more than 30% of the door area in several locations. Specifically, these locations included the third floor resident room 316, the second floor bathroom door next to the nurses station, and the second floor soiled utility room door. An interview with the administrator and maintenance director confirmed these deficiencies related to combustible decorations.
Plan Of Correction
1. Maintenance Director or designee immediately removed combustible decorations from three doors. 2. Education will be provided to the maintenance department by Administrator or designee on the potential hazards with combustible decorations. 3. Maintenance Director or designee will audit weekly x 4 weeks and monthly x 1 month. 4. Results will be discussed with QA committee with monitoring if applicable.
Penalty
Surveyors found combustible decorations on two floors, including items obstructing a corridor egress pathway and santa banners pinned to a fire and smoke door near a nurse station, with no fire retardant documentation available and the integrity of the fire door compromised. The maintenance director confirmed these deficiencies.
The facility was found to have a deficiency related to combustible decorations, as the door to a resident's room had decorations exceeding allowable coverage. This was confirmed by the maintenance supervisor.
The facility was found to have combustible decorations on fire doors in the Walnut Street wing, near a resident room, that exceeded allowable coverage and lacked documentation of fire-proofing treatment. This deficiency was confirmed by the maintenance supervisor during the survey.
Combustible Decorations Obstruct Egress and Compromise Fire Door Integrity
Penalty
Summary
Surveyors observed that the facility failed to properly maintain combustible decorations on two of its five floors. On the first floor, combustible decorations were found plugged into the corridor, obstructing the full use of the egress pathway. Additionally, there was no documentation available at the time of the survey to confirm that these decorations were treated with fire retardant. On the second floor, santa banners were pinned to a fire and smoke door near the nurse station, which compromised the integrity of the door. These deficiencies were confirmed during an interview with the maintenance director, who acknowledged the issues with the combustible decorations. The observations were made during a survey conducted between 9:04 a.m. and 10:03 a.m. on December 19, 2025. No information about specific residents or their conditions was provided in the report.
Plan Of Correction
The systematic change will be to have the Christmas decorations that were in the hallway and covering doors be removed in total. The Administrator or designee will limit holiday materials in the hallway and doors, and the Administrator or designee will review holiday materials prior to placing them in the facility.
Combustible Decoration Deficiency on Resident Room Door
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding combustible decorations. During an observation on January 29, 2025, at 11:13 a.m., it was noted that the door to resident room #116 had decorations that exceeded the allowable coverage as per the fire safety regulations. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the presence of excessive combustible decorations on the door.
Plan Of Correction
Resident's door decorations removed immediately. Resident, Family, and staff educated on the regulation. Doors will be monitored weekly for 4 weeks then monthly. Results will be reviewed at the QAPI meeting.
Combustible Decoration Deficiency in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding combustible decorations. During an observation on January 14, 2025, it was noted that the fire doors in the Walnut Street wing, specifically near resident room #245, had decorations that exceeded the allowable coverage of materials. Additionally, there was no documentation available to confirm that these decorations had been treated with fire, flame, or smoke-proofing applications. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the presence of the combustible decoration issue at the time of the survey.
Plan Of Correction
The decorative item was removed from the door. All doors in the facility were checked to ensure the allowable coverage was not compensated. All staff were educated in monthly in-service meetings of code and appropriate allotment of coverage along with advising maintenance when something is on a door. The NHA & facility maintenance director will audit weekly for one month and monthly thereafter.
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