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NY State Tag
D

Excessive Storage of Alcohol-Based Hand Sanitizer

Kenmore, New York Survey Completed on 01-08-2025

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

During a Life Safety Code survey, it was observed that the facility stored an excessive amount of alcohol-based hand sanitizer in the basement, exceeding the allowable limit set by the 2012 NFPA 30 code. Specifically, 54 containers, each holding 1.2 liters of sanitizer with 76 percent alcohol content, were found on open shelving in the Main Storage Room, totaling 64.8 liters or 17.1 gallons. This storage practice did not comply with the requirement to store such quantities in a flammable liquids storage cabinet. The facility lacked a Director of Plant Operations for a period, during which another individual continued ordering supplies, inadvertently leading to the accumulation of excess sanitizer. Additionally, the facility did not have a policy in place regarding the storage of alcohol-based hand sanitizers.

Plan Of Correction

Plan of Correction: Approved February 5, 2025 Corrective action for affected area: The excess alcohol-based hand sanitizer was removed from the Main Store room. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice; all storage areas were checked for alcohol-based hand sanitizer. Steps to prevent further recurrence: Measures to be put in place include a monthly audit of the Main Store room to monitor the amount of alcohol-based hand sanitizer in stock. An updated policy was implemented to ensure safe use and storage of alcohol-based hand sanitizer. Maintenance staff will be educated to ensure containers of alcohol-based hand sanitizer in an aggregate amount of greater than ten gallons are not stored in a single smoke compartment outside of a flammable liquids storage cabinet. How corrective action will be monitored: Monthly audit will be reviewed by administration and reported to the Quality Assurance Committee. The Director of Plant Operations will be responsible to ensure compliance.

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