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K0923
E

Oxygen Storage Deficiencies in Basement

North Wales, Pennsylvania Survey Completed on 02-10-2025

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 maintain proper oxygen storage requirements, as observed during a survey on February 10, 2025. In the basement oxygen storage room, combustible boxes were stored directly next to oxygen cylinders, which is a violation of safety protocols. This improper storage poses a risk as oxidizing gases should not be stored with flammable materials, and there should be a separation of at least 20 feet, or 5 feet if the area is sprinklered, from combustibles. Additionally, the facility did not separate empty portable oxygen cylinders from full ones in the same storage room. This lack of segregation can lead to confusion and potential safety hazards, as it is essential to clearly distinguish between full and empty cylinders to ensure proper usage and storage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.

Plan Of Correction

Combustible boxes were removed from the oxygen storage room next to cylinders located in the basement. Empty portable oxygen cylinders were separated from full cylinders in the basement storage room. All oxygen storage areas will be checked for proper storage of cylinders. The maintenance director will in-service Material Management on proper oxygen storage requirements. The maintenance director/designee will audit O2 storage areas for proper storage of cylinders weekly X3 and report findings to QAPI.

See complete original report
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