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K0351
F

Incomplete Sprinkler System Installation in Electrical Room

Bryn Mawr, Pennsylvania Survey Completed on 04-15-2025

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 install required sprinkler system components, specifically in the Main electrical (switchgear) Room located in the basement. This deficiency was identified during an observation on April 15, 2025, at 11:25 a.m. The absence of an automatic sprinkler system in this area was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. This oversight affects one of the three levels of the facility, indicating incomplete automatic sprinkler protection as per the requirements outlined in NFPA 101 and NFPA 13 standards.

Plan Of Correction

1) The facility contractor is submitting plans to the Plan Review Department for approval of modifications to the fire suppression system for approval. 2) The Maintenance Director and/or designee will inspect the Main Electrical Room once a suitable fire suppression system is installed. 3) To prevent the potential for reoccurrence, the Administrator will educate the Maintenance Director and/or designee on the importance of a suitable fire suppression system is installed. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will check the fire suppression system is in place as required monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.

See complete original report
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