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K0131
E

Failure to Maintain Building Separation

Newtown Square, Pennsylvania Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

See complete original report
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