Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
K0353
F

Failure to Maintain Sprinkler System Testing

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

Penalty

No penalty information released
tooltip icon
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 the required testing of automatic sprinkler system components, which affected the entire facility. During a document review on March 17, 2025, it was revealed that the quarterly sprinkler inspection reports for both wet and dry systems, dated January 20, 2025, indicated that the last full flow trip test for the dry system was conducted in 2019. This finding was confirmed during an exit interview with the Administrator and Maintenance Director on the same day, highlighting that the testing was out of the mandated three-year testing cycle.

Plan Of Correction

Full flow trip test is scheduled for 4/28/2025. A task will be entered in TELS work order system to ensure tests are completed timely. Maintenance director will report on the results and compliance to QAPI committee.

See complete original report
An unhandled error has occurred. Reload 🗙