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K0161
C

Building Construction Type Exceeds Allowable Story Height

Bryn Mawr, Pennsylvania Survey Completed on 03-17-2025

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 was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview conducted on March 17, 2025, it was discovered that the facility was classified as a two-story, Type III (200), unprotected ordinary construction, which was fully sprinklered. However, this classification exceeded the maximum allowable story height by one story, as the construction type only permits a maximum of two stories when sprinklered. This discrepancy was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another component of the facility was identified as a two-story, Type II (000), unprotected noncombustible construction with a basement, which was also fully sprinklered. This component similarly exceeded the maximum allowable story height by one story, as the construction type does not allow for any stories when non-sprinklered and only permits one story when sprinklered. This finding was also confirmed during the exit interview with the facility's Administrator and Maintenance Director.

Plan Of Correction

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 has previously submitted a waiver for 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. 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 has submitted a TLW waiver for 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.

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