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AVERA TYLER HOSPITAL
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 8.5.6.4, 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.1.1.2, and 5.3.2.1. These deficient findings could have a widespread impact on the residents within the facility.
Findings include:
1. On 04/16/2025 between 9:30 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey, the facility could not provide a fire sprinkler 5-year inspection report.
2. On 04/16/2025 at between 9:30AM and 1:00 PM, it was revealed by observation that the escutcheon plates were missing in room 109.
An interview with the Environmental Service Manager verified these deficient findings at the time of discovery.
Corridor - Doors
Tag No.: K0363
Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5. These deficient findings could have a patterned impact on the residents within the facility.
Findings include:
1. On 04/16/2025 between 9:30 AM and 1:00 PM, it was revealed by observation that the door to the soiled utility room could not positively latch.
2. On 04/16/2025 between 9:30 AM and 1:00 PM, it was revealed by observation that door 404 did not positively latch when tested.
An interview with the Environmental Service Manager verified these deficient findings at the time of discovery.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, NFPA 70, (2011 edition), National Electrical Code, sections 400.8, and UL 1363. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 04/16/2025 between 9:30 AM and 1:00 PM, it was revealed by observation that the tv in the Solarium was plugged into a 3-way plug, that was being powered by an extension cord.
An interview with the Environmental Service Manager verified this deficient finding at the time of discovery.