Deficient Fire Separation in Facility Occupancies
Summary
The facility failed to ensure that sections of health care facilities classified as other occupancies were properly separated from areas of healthcare occupancies by construction with a two-hour fire resistance rating. This deficiency was identified during observations and interviews conducted on December 19, 2024. Specifically, the separation between the Healthcare occupancy and the Residential occupancy was compromised by a 1.5-inch and 2.5-inch unprotected penetration for wire pass-throughs. Additionally, a 2-inch-high by 48-inch-wide section of brick was missing above the fire-rated door assembly between the two occupancies. These observations were confirmed by the USTFOTAT at the time of the inspection. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference on December 20, 2024.
Plan Of Correction
1/9/25 1. All residents have the potential to be affected by this deficient Life Safety Code. The maintenance department repaired the 2 unprotected penetrations for the pass-through of wires on 1/8/25 using UL listed NUEX Order 26.4(DX LC 150 fire-stop sealant. The maintenance department repaired the 2 inch by 48 inch wide section of brick missing above the fire rated door assembly between the two occupancies on 1/8/25 using intumescent fire-stop pillows and UL listed NJ Ex Order 26.4(15) LC 150 fire-stop sealant. 2. The facility's maintenance schedule will be revised by the Director of Maintenance to include a monthly inspection of fire-rated assemblies between the healthcare occupancy and the residential occupancy to confirm that the two hour fire resistance rating is intact with no penetrations using an audit tool. 3. The Director of Maintenance will review the fire rated assembly inspection reports monthly ongoing and report the results to the administrator and to the QAPI committee monthly for 6 months.
Penalty
Surveyors identified that fire-rated doors in the basement elevator lobby area had multiple penetrations and extensive damage, compromising the required fire resistance rating for common wall separations. Facility leadership confirmed these deficiencies during interviews.
The facility failed to maintain proper building separation in sections classified as other occupancies. An observation revealed that the doorway to Country House, between skilled nursing and assisted living, lacked a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance, acknowledging the lack of complete two-hour fire-resistant separation.
The facility failed to maintain a two-hour fire resistance rating between the main building and the west wing due to a door that did not latch properly, affecting one of the smoke compartments. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility did not maintain the fire resistance rating of common walls, as observed by an unsealed penetration around data wires above the doors separating Willowbrooke Court and the Independent Living Unit. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain fire resistance in common wall separations as certain fire-rated doors did not positively bottom latch. Observations revealed that the double doors at Tony's Café and a level fire door in the basement, both separating different components, failed to latch properly. This was confirmed during an exit interview with the Facility Administrator and Director of Maintenance.
The facility failed to maintain the fire resistance rating of common wall fire separations, affecting one of three levels. The rated double doors near the basement loading dock did not fully close and positively latch when tested. This was confirmed during an exit interview with the Administrator and Maintenance Director.
Failure to Maintain Fire-Resistant Door Barriers
Penalty
Summary
Surveyors observed that the facility failed to maintain the required fire resistance rating for common wall fire separations in one of three levels. Specifically, during an inspection, deficiencies were identified with fire-rated doors in the basement elevator lobby area. One double fire door had several penetrations on the door leaf and in the metal door frame, and another fire door showed penetrations and extensive damage at each hinge location. These conditions were directly observed by surveyors during their walkthrough. The deficiencies were confirmed in interviews with the Administrator and Maintenance Director, who acknowledged the issues with the fire doors. The report does not mention any specific patients or residents affected, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the findings is on the physical environment and the failure to maintain fire-resistant barriers as required by NFPA 101 standards.
Plan Of Correction
The fire door with penetrations has been replaced. Other fire doors in the center will be checked to ensure that they are free of penetrations. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire doors are free from penetrations. Results of the audits will be reported to QAPI.
Failure to Maintain Building Separation
Penalty
Summary
The facility failed to maintain proper building separation in sections classified as other occupancies. During an observation on April 17, 2025, at 9:50 a.m., it was noted that the doorway to Country House, which is situated between the skilled nursing and assisted living areas, did not have a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m., where it was acknowledged that there was a lack of complete two-hour fire-resistant separation as required by the regulations.
Plan Of Correction
2-hour fire resistant doors will be purchased and installed by 7/11/2025 by Dunwoody's General Contractor. The Maintenance Manager or designee will inspect these doors weekly for the initial two months and then annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 7/11/2025. Dunwoody will ask for a TLW as July 11 is close to the 90th day and if there is any type of delay by contractor or delivery or production of door it may be necessary to have the TLW.
Failure to Maintain Fire Resistance Rating in Facility
Penalty
Summary
The facility failed to maintain a two-hour fire resistance rating to separate buildings of different construction types, specifically between the main building and the west wing. This deficiency was identified during an observation on February 3, 2025, when it was noted that the door between these two areas did not latch properly in its frame when tested. This issue affects one of the twenty-six smoke compartments within the facility. The deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on February 4, 2025, at 2:00 p.m. They acknowledged the problem with the doors in the two-hour rated occupancy separation wall, which is a requirement under NFPA 101 for maintaining fire safety standards in health care facilities. The failure to ensure proper latching of the door compromises the intended fire resistance rating, which is crucial for the safety of the facility's occupants.
Plan Of Correction
131 1. The Door between west wing and main building was corrected to securely latch in its frame. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to assess doors across the campus to ensure they latch to their frame. 131 main 2 1. The Door between west wing and main building was corrected to securely latch in its frame. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to assess doors across the campus to ensure they latch to their frame.
Failure to Maintain Fire Resistance Rating in Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance rating of common walls, which is a requirement for sections of health care facilities classified as other occupancies. During an observation, it was noted that there was an unsealed penetration around data wires above the common wall doors separating Willowbrooke Court and the Independent Living Unit. This deficiency was identified on one of the two levels of the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of State and Federal Law. The plan of corrections represents the community's credible allegation of compliance. Maintenance technician sealed the identified penetrations around the data wires above the common wall doors separating Willowbrooke Court and Independent Living Unit using UL system WL-3423 on 1/29/2025. The Maintenance Department will be in-serviced by 2/14/2025 the Director of Property Management/ Designee on maintaining the fire resistance rating of common walls. All fire door separations in Willowbrooke Court were audited by 2/12/2025 by maintenance technician for penetrations and maintenance of fire rating. The Director of Property Management or designee will conduct random weekly audits x4 weeks to check fire resistance rating of common walls, affecting one of two levels. All findings will be reported to QAPI Committee.
Failure to Maintain Fire Resistance in Common Wall Separations
Penalty
Summary
The facility failed to maintain fire resistance in common wall fire separations within one of its components. During an observation on January 27, 2025, between 9:05 a.m. and 9:45 a.m., it was noted that certain fire-rated doors did not positively bottom latch when tested. Specifically, at 9:05 a.m., the double doors on the first floor at Tony's Café, which separate Component 1 from Component 2, failed to latch. Additionally, at 9:45 a.m., the level fire door in the basement, also separating Component 1 from Component 2, did not latch properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Director of Maintenance.
Plan Of Correction
The doors and door hardware will be adjusted so the door will positively latch into the frame. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
Fire Resistance Deficiency in Facility
Penalty
Summary
The facility failed to maintain the fire resistance rating of common wall fire separations, specifically affecting one of the three levels within the facility. During an observation on January 13, 2025, at 9:00 a.m., it was noted that the rated double doors near the basement loading dock did not fully close and positively latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
Rated Double Door has been adjusted to ensure the doors are smoke tight, close and positively latch to maintain their fire rating. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure doors are smoke tight. All audits will be reviewed by The Senior Director of Property and Facilities and submitted to the Quality Assurance Performance Improvement Committee on a monthly basis for 12 months.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
