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K0241
B

Facility Lacks Two Acceptable Exits in Basement

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 provide two acceptable exits, located remotely from one another, affecting one of two floors of the building. During a document review on March 17, 2025, it was revealed that the basement level of the facility lacked two acceptable emergency exits that are located remotely from each other. Specifically, the north exit from the basement is a communicating stair and does not lead to an exterior exit discharge. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day, where it was acknowledged that the basement level lacked two acceptable exits.

Plan Of Correction

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.

See complete original report
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