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LAKEWOOD HEALTH SYSTEM
Combustible Decorations
Tag No.: K0753
Based on observation and interview, the facility did not restrict the use of flammable decorations, including candles, in accordance with the requirements of NFPA 101 Life Safety Code, 2012 edition, section 19.7.5.6. These deficient findings could have an isolated impact on the residents within the facility.
Findings include:
On 04/01/2025 at 09:19 AM, it was revealed by observation there were 134 candles with intact wood wicked candles in the gift shop, after meeting with the Maintenance Director and a guided tour was then made of the gift shop and they were told to remove them. The staff in the gift shop understood and said they would remove them and when this surveyor walked by again at approximately 11:30 AM they were still on display.
An interview with the Maintenance Director verified these deficient findings at the time of discovery.