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K0918
C

Emergency Generator Maintenance Deficiency

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 failed to maintain required emergency generator components, which affected the entire facility. During an observation on March 17, 2025, it was noted that the emergency generator set location inside the transformer room in the basement lacked battery back-up emergency lighting. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. Additionally, a documentation review revealed that the facility did not have the required 3-year, 4-hour load test report available for the generator that supports the emergency electrical system. This lack of documentation was also confirmed during the exit interview with the Administrator and Maintenance Director.

Plan Of Correction

Emergency lighting installation is scheduled for 4/21/2025. A 4-hour load test was completed on 3/31/2025. A task will be entered in TELS work order system to ensure tests are completed timely. The maintenance director will report on results to the QAPI meeting.

See complete original report
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