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K0929
E

Unsecured Portable Oxygen Cylinders

Hanover, Pennsylvania Survey Completed on 02-12-2025

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 secure portable oxygen cylinders, which is a requirement under NFPA 99 standards for handling gas equipment. During an observation on February 12, 2025, at 2:00 PM, five unsecured 'E' size portable oxygen cylinders were found outside the Oxygen Storage Room, within a first-floor room by SC-5. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the unsecured state of the oxygen cylinders. This issue affected one of the seven smoke compartments within the component.

Plan Of Correction

1. Cylinders were placed back into proper storage area after observation. 2. Facility will provide re-education to staff regarding appropriate storage of oxygen cylinders. 3. Maintenance director/designee will complete audits of storage areas monthly to ensure they are properly stored. Audits will be reviewed at QAPI to ensure compliance.

See complete original report
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