Combustible Decoration Deficiency on Resident Room Door
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
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.