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

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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 February 19, 2026, it was determined that Bryn Mawr Village had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients:

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.

§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Observations:
Name: - Component: -- - Tag: 0035 Based on document review and interview, it was determined the facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan, that the facility has determined appropriate, with residents and their families or representatives. Findings include: 1. Document review and interview on February 19, 2026, at 8:15 am, revealed the emergency communications plan did not include a method of sharing information from the emergency plan with residents and their families or representatives, affecting the entire facility. Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 –The facility updated the Emergency Preparedness Communication Plan to include a method for sharing information from the emergency plan with residents and their families or representatives. A communication letter outlining the facility's emergency communication process was created and implemented.

Step 2 – The communication notice was posted in common areas of the facility including the lobby, nurses' stations, and activity areas to ensure residents and visitors have access to the information. The emergency communication notice was also added to the facility admission packet to ensure all new residents and responsible parties receive the information upon admission.

Step 3 –The Administrator or designee provided education to department heads and admissions staff regarding the updated Emergency Preparedness Communication Plan and the process for distributing the communication notice to residents and responsible parties.

Step 4 – The Administrator or designee will audit admission packets and posting locations weekly for four (4) weeks and monthly thereafter for two (2) months to ensure the communication notice remains in place and included in admission materials. Results will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036 Based on documentation review and interview, it was determined the facility failed to developan emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility. Findings include: 1. Document review and interview on February 19, 2026, at 8:15 am, revealed the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility reviewed and updated the Emergency Preparedness Training to ensure it aligns with the facility's Emergency Preparedness Plan. The facility did conduct Emergency Preparedness education with staff; however, the training program documentation was not formally maintained. Documentation of the emergency preparedness training program and testing process has now been developed and implemented using Relias.

Step 2 – The facility established a formal Emergency Preparedness Training and Testing Program based on the Emergency Preparedness Plan using Relias. The program will include annual review and updates to ensure compliance and continued alignment with regulatory requirements.

Step 3 – The Administrator or designee provided education to department heads and staff regarding the Emergency Preparedness Plan and the facility's Emergency Preparedness Training and Testing Program, including expectations for annual training and documentation.

Step 4 – The Administrator or designee will audit the Emergency Preparedness Training and Testing Program quarterly for three months to ensure training documentation is maintained and the program remains current. Results will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037 Based on documentation review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility. Findings include: 1. Document review and interview on February 19, 2026, at 8:15 am, revealed the facility failed to perform training to the emergency preparedness plan that included the following: a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. b. Provide emergency preparedness training at least annually. c. Maintain documentation of the training. d. Demonstrate staff knowledge of emergency procedures. Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility reviewed the Emergency Preparedness Plan and Training Program. Emergency preparedness education had been provided to staff; however, documentation of the training program was not formally maintained. The facility has now implemented a formal Emergency Preparedness Training Program, which includes initial training for new staff, annual training for all staff, and documentation of training completion.

Step 2 – The facility established a structured Emergency Preparedness Training and Testing Program based on the Emergency Preparedness Plan using RELIAS. The program now includes initial training for new employees, contracted staff, and volunteers as applicable, annual training for existing staff, and maintained documentation of training completion and staff competency related to emergency procedures.

Step 3 –The Administrator or designee provided education to department heads and staff regarding the Emergency Preparedness Plan and the required training expectations, including staff roles during emergencies and the requirement for documented training.

Step 4 – The Administrator or designee will audit emergency preparedness training records weekly for four (4) weeks and monthly thereafter for two (2) months to ensure training documentation is maintained and staff education is completed. Results will be reviewed through QAPI, and corrective action will be implemented if concerns are identified.

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 February 19, 2026, 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 Egress Doors:

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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0222 Based on observation and interview, it was determined the facility failed to maintain exit doors with special locking arrangements, affecting one of two levels in the component. Findings include: Observation on February 19, 2026, at 10:55 am, revealed, on the ground floor, the exit door from Impressions contained signage the door was a delayed egress door. The door is no longer a delayed egress door.Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the improper signage on the door.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility immediately removed the incorrect delayed egress signage from the exit door located in the Impressions area on the ground floor. The door was inspected to ensure it was functioning properly and that signage accurately reflects the door's current operation.

Step 2 –The Maintenance Director or designee reviewed all exit doors throughout the facility to ensure signage accurately reflects the door hardware and locking arrangements. Any incorrect or outdated signage was removed or corrected.

Step 3 – The Maintenance Director or designee provided education to maintenance staff regarding Life Safety requirements related to exit doors, special locking arrangements, and appropriate signage to ensure signage accurately reflects the function of the door.

Step 4 – The Maintenance Director or designee will audit exit doors and associated signage weekly for four (4) weeks and monthly thereafter for two (2) months to ensure proper signage and function are maintained. Findings will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of two levels in the component. Findings include: Observation on February 19, 2026, at 10:25 am, revealed, on the second floor, Medical Equipment Room 24 lacked a self closer.Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of self closer.

Plan of Correction - To be completed: 04/14/2026

Step 1 – A self-closing device was installed on the door to Medical Equipment Room 24 on the second floor to ensure the hazardous area enclosure maintains proper smoke resistance in accordance with Life Safety Code requirements.

Step 2 – The Maintenance Director or designee conducted a facility-wide review of hazardous area doors to ensure all required doors are equipped with properly functioning self-closing devices.

Step 3 – The Maintenance Director or designee provided education to maintenance staff regarding Life Safety Code requirements for hazardous area enclosures, including the requirement for doors to be self-closing and maintained in proper working condition.

Step 4 – The Maintenance Director or designee will audit hazardous area doors weekly for four (4) weeks and monthly thereafter for two (2) months to ensure required self-closing devices remain in place and functioning properly. Results will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

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 maintain and inspect kitchen hood exhaust systems, affecting the entire facility. Findings include: Document review and interview on February 19, 2026, at 8:15 am, revealed the facility failed to provide documentation showing semi-annual kitchen hood exhaust cleanings were completed within the past twelve months.Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility contacted the vendor responsible for kitchen hood exhaust cleaning to schedule the required service. Documentation of the semi-annual kitchen hood exhaust cleaning will be obtained and maintained on-site.

Step 2 – The Maintenance Director or designee established a preventative maintenance schedule to ensure kitchen hood exhaust systems are inspected and cleaned semi-annually in accordance with Life Safety Code requirements. Documentation of services will be maintained in the facility's Life Safety compliance binder.

Step 3 – The Administrator or designee provided education to the Maintenance Director regarding required documentation and scheduling of semi-annual kitchen hood exhaust inspections and cleanings.

Step 4 – The Administrator or designee will audit the Life Safety documentation quarterly for three months to ensure required inspection and cleaning records are maintained. Results will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility. Findings include: Document review and interview on February 19, 2026, at 8:15 am, revealed the following deficiencies:The facility could not produce documentation showing an annual fire alarm inspection was completed within the past twelve months;The facility could not provide documentation showing smoke detector sensitivity testing was completed within the past twenty four months.Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility contacted the fire alarm vendor to schedule the required annual fire alarm system inspection and smoke detector sensitivity testing. Documentation of the completed inspection and testing will be obtained and maintained in the facility's Life Safety documentation records.

Step 2 – The Maintenance Director or designee implemented a preventative maintenance schedule to ensure the annual fire alarm inspection and required smoke detector sensitivity testing are completed within regulatory timeframes. All inspection and testing documentation will be maintained in the Life Safety compliance binder.

Step 3 –The Administrator or designee provided education to the Maintenance Director regarding required fire alarm system inspection schedules and documentation requirements to ensure compliance with Life Safety Code standards.

Step 4 –The Administrator or designee will audit Life Safety inspection documentation quarterly for three months to ensure required fire alarm inspection and smoke detector sensitivity testing records are maintained. Results will be reviewed through QAPI, and corrective action will be implemented if concerns are identified.

NFPA 101 STANDARD Evacuation and Relocation Plan:

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Observations:
Name: BLDG 01 (MAIN HEALTHCARE BUILDING) - Component: 01 - Tag: 0711 Based on document review and interview, it was determined the facility failed to provide a fire alarm evacuation plan, effecting the entire facility. Findings include: 1. Document review on February 19, 2026, at 8:15 am, revealed the facility could not provide a fire alarm evacuation plan. Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility developed and implemented a Fire Alarm Evacuation Plan outlining procedures for resident evacuation in the event of a fire alarm activation. The evacuation plan has been placed in the facility's Life Safety documentation binder and made accessible to staff.

Step 2 – The facility incorporated the Fire Alarm Evacuation Plan into the facility's Emergency Preparedness and Life Safety Program to ensure the plan is maintained, readily available, and reviewed during annual Life Safety and emergency preparedness reviews.

Step 3 –The Administrator or designee provided education to department heads and staff regarding the Fire Alarm Evacuation Plan, including staff roles and responsibilities during a fire alarm activation and evacuation procedures.

Step 4 –The Administrator or designee will audit Life Safety documentation weekly for four (4) weeks and monthly thereafter for two (2) months to ensure the Fire Alarm Evacuation Plan remains in place and accessible. Findings will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

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 ensure rated fire door assemblies were inspected and tested annually, affecting the entire facility. Findings include: 1. Document review on February 19, 2026, at 8:15 am, revealed the facility could not provide documentation that rated fire door assemblies were inspected and tested within the previous 12 months. Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 – The facility contacted the appropriate vendor as needed to schedule the annual inspection and testing of rated fire door assemblies. Documentation of the completed inspection and testing will be obtained and maintained in the facility's Life Safety documentation binder.

Step 2 – The Maintenance Director or designee implemented a preventative maintenance schedule to ensure annual inspection and testing of rated fire door assemblies is completed in accordance with Life Safety Code requirements. All inspection documentation will be maintained on-site.

Step 3 – The Administrator or designee provided education to the Maintenance Director regarding the required inspection schedule and documentation for rated fire door assemblies.

Step 4 –The Administrator or designee will audit Life Safety inspection documentation quarterly for three months to ensure required inspection records are maintained. Results will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility. Findings include: Document review on February 19, 2026, at 8:15 am, revealed the facility could not provide documentation showing an annual fuel quality test was completed within the past twelve months.Exit review with the Administrator and Maintenance Director on February 19, 2026, at 11:15 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 04/14/2026

Step 1 –The facility contacted the generator service vendor to schedule the required annual fuel quality test for the emergency generator. Documentation of the completed fuel quality test will be obtained and maintained in the facility's Life Safety documentation binder.

Step 2 –The Maintenance Director or designee implemented a preventative maintenance schedule to ensure the annual fuel quality test and all required generator inspections are completed within regulatory timeframes. Documentation will be maintained on-site.

Step 3 –The Administrator or designee provided education to the Maintenance Director regarding required emergency generator inspection schedules and documentation requirements, including annual fuel quality testing.

Step 4 –The Administrator or designee will audit Life Safety documentation quarterly for three months to ensure generator inspection and fuel quality testing records are maintained. Findings will be reviewed through QAPI, and corrective action will be taken if concerns are identified.

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 February 19, 2026, at Bryn Mawr Village - Physical Therapy, Garage and the Dietary Storage Area, it was determined that there were no deficiencies identified under the 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:

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 February 19, 2026, at Bryn Mawr Village - New Addition, it was determined there were no deficiencies identified under the 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:

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