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Based on observation and staff interview the facility failed to provide corridors safe from excessive combustible decorations. The deficient practice of assuring that combustible decorations are flame retardant or treated with approved fire-retardant coating could provide additional fuels than can ignite in the event of a fire in escape pathways. This deficiency affects all residents and staff in 1 of 8 smoke zones. The facility has a capacity of 26 with a census of 10 at the time of survey.

Findings include:

During the portion of the tour conducted on 12/14/18 at 3:08 p.m., it is observed that the facility has an artificial Christmas tree located on the 2nd floor in the south corridor. No documentation was available to assure that the tree is flame retardant or treated with approved fire-retardant coating that is listed and labeled for product or that the trees meet NFPA 701.

Staff M-1 and Staff M-2 were present at the time of the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is met:
o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product.
o Decorations meet NFPA 701.
o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289.
o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6