Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by missing precautionary signage in two locations. During observations conducted on January 30, 2025, between 11:00 a.m. and 11:15 a.m., it was noted that the North Nurses Station Med Rooms on both the second and first floors lacked the required precautionary signage on their entry doors. The signage should have included the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. The absence of the necessary signage indicates a failure to comply with the National Fire Protection Association (NFPA) standards for gas equipment storage, specifically regarding the storage of oxidizing gases. This oversight affects two of the three floors in the facility, potentially compromising safety protocols related to oxygen storage.
Plan Of Correction
Step 1 Caution signage was installed in 1 North and 2 North nursing station med room. Step 2 A facility-wide audit was completed to ensure that oxygen storage areas have the appropriate caution signage. Step 3 The maintenance team was educated on the requirement to monitor the oxygen storage area and ensure they have appropriate caution signage. Step 4 The maintenance director/designee will audit oxygen storage areas monthly x4. Findings will be reviewed during QAPI meeting.