Non-compliance with Combustible Decoration Standards
Penalty
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.