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.