Pennsylvania Department of Health
BRYN MAWR VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 46 surveys for this facility. Please select a date to view the survey results.

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BRYN MAWR VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 14, 2024, at Bryn Mawr Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0000

Facility ID# 023402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2024, it was determined that Bryn Mawr Village - Main Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type III (200), unprotected ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire building component.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed the facility was classified as a two story, Type III (200), unprotected ordinary construction, fully sprinklered. The story height exceeds the maximum allowance for this construction type by one story.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the building exceeded the maximum allowable story height by one story.

Plan of Correction - To be completed: 07/01/2024

Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered, the story height exceeds the maximum allowance for this construction type one story. The facility is also requesting a TLW which will be submitted with the POC.
The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions, affecting one of two levels.

Findings include:

Observation on May 14, 2024, at 10:30 a.m., revealed on the second floor, East wing exit door required excessive force to open.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the excessive force to open the exit door.

Plan of Correction - To be completed: 07/01/2024

Exit door was repaired on May 15th 2024. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Vertical Openings - Enclosure:

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0311

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting two of two levels within this component.

Findings include:

1. Document review on May 14, 2024, at 9:30 a.m., revealed the communicating stairway, between the Lower Level Kitchen and the First Floor, lacked one hour fire resistive construction.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the stairs lacked the one-hour fire resistive construction.

Plan of Correction - To be completed: 07/01/2024

The facility will work with an outside consultant to complete an FSES to cover this deficiency.
The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting two of two inspections.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing the kitchen suppression system inspection had been performed twice in the prior year.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/01/2024

Documentation of kitchen suppression system inspection was obtained by the maintenance director. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0353

Based on observation, document review and interview, it was determined the facility failed to maintain sprinkler systems, affecting one of two levels.

Findings include:

1. Document review on May 14, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing a third quarter 2023 sprinkler inspection had been conducted as required.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the missing documentation.

2. Observation on May 14, 2024, at 10:00 a.m., revealed the ceiling had dropped around a sprinkler, which could obstruct the spray pattern, front entrance reception area.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the obstructed sprinkler.

Plan of Correction - To be completed: 07/01/2024

1) the 2023 3rd quarter sprinkler was performed at the required time. Documentation of the inspection was obtained by the maintenance director.
2) The ceiling in the lobby area will be repaired by June 3rd 2024. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas, affecting one of two levels.

Findings include:

Observation on May 14, 2024, at 11:15 a.m., revealed a facility employee smoking near to the building. This is not the designated smoking area.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the employee smoking outside the designated smoking area.

Plan of Correction - To be completed: 07/01/2024

"No Smoking" signs were immediately installed in the areas outside the designated area. Staff education was initiated to ensure compliance going forward. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to conduct annual fire door inspections, for one of one required inspection.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing an annual fire door inspection was performed.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/01/2024

The annual fire door inspection was performed at the required time, documentation of the inspection was obtained by the maintenance director. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting two generators.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed annual fuel quality test results for the emergency generators diesel fuel were not available for review at time of survey.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/01/2024

The fuel Quality test was performed on May 23rd 2024. The test report will be sent to the maintenance director by June 7th 2024. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices, affecting one of two levels.

Findings include:

Observation on May 14, 2024, at 10:50 a.m., revealed a fridge plugged into a surge protector, in Scheduler's Office on the second floor .

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 07/01/2024

The refrigerator was immediately removed from the surge protector and plugged directly into the wall outlet. Staff were educated on the regulations of not using surge protectors for appliances. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

Initial comments:Name: BLDG 02 (DINING ROOM, GARAGE, DIETARY STORAGE) - Component: 02 - Tag: 0000

Facility ID# 023402
Component 02
Physical Therapy, Garage and the Dietary Storage Areas

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2024, it was determined that Bryn Mawr Village - Physical Therapy, Garage and the Dietary Storage Area were not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association ' s Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BLDG 02 (DINING ROOM, GARAGE, DIETARY STORAGE) - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of doors in common walls, affecting one of two levels within this component.

Findings Include:

Observation made on May 14, 2024, at 11:45 a.m., revealed at the Physical Therapy Office on the second floor, rated door failed to self-close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the common wall door failed to latch.

Plan of Correction - To be completed: 07/01/2024

The door latch was repaired on May 15th 2024, the penetration was repaired on May 31st 2024. he Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

Initial comments:Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0000

Facility ID# 023402
Component 03
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2024, it was determined that Bryn Mawr Village - New Addition was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

Observations:
Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two levels.

Findings Include:

Observation made on May 14, 2024, at 10:45 a.m., revealed on the second floor above the fire doors to Main Building, an unsealed penetration at mortar joint.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the unsealed penetration.

Plan of Correction - To be completed: 07/01/2024

The penetration was repaired on May 30th 2024, the penetration was repaired on May 31st 2024. he Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire building component.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed this component was classified as a two-story, Type II (000), unprotected noncombustible construction, with a basement, which is fully sprinklered, exceeds the maximum allowable story height by one story.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the building exceeded the maximum allowable story height by one story.

Plan of Correction - To be completed: 07/01/2024

Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistants with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered, the story height exceeds the maximum allowance for this construction type one story. The facility is also requesting a TLW which will be submitted with the POC.
The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0241

Based on document review and interview, it was determined the facility failed to provide two acceptable exits, located remotely from one another, affecting one of two floors of the building.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed, the Basement level lacks two acceptable emergency exits located remotely from each other. The north exit from the basement is a communicating stair and does not lead to an exterior exit discharge.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the basement level lacked two acceptable exits.

NFPA 101 STANDARD Number of Exits - Corridors:

Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4

Observations:
Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0252

Based on document review and interview, it was determined the facility failed to ensure acceptable exits to grade, affecting one of two locations.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed the north exit, from the Second Floor, is through an intervening dining room.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the exiting deficiency.

NFPA 101 STANDARD Vertical Openings - Enclosure:

Observations:
Name: BLDG 03 (NEW ADDITION) - Component: 03 - Tag: 0311

Based on document review and interview, it was determined the facility failed to maintain stair towers with a fire resistance rating, affecting one of two floors within this building component.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed the north side exit from the Basement, is a communicating staircase with walls not sheathed on the room 2A side, and therefore does not have the required one-hour fire resistance rating.

Exit Interview with the Administrator and Maintenance Director on May 14, 2024, at 12:15 p.m., confirmed the lack of fire resistance rating of the stairway.

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