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.