Oxygen Storage Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as observed during a survey on January 30, 2025. At 10:20 a.m., it was noted that the oxygen cabinet in the AO level clean utility room did not latch properly, which is a violation of the storage requirements for gas equipment. This deficiency indicates that the facility did not ensure that the storage locations were secure, as required by the guidelines for handling and storing oxygen cylinders. Additionally, at 11:15 a.m., in the D1 level oxygen storage room, empty portable oxygen cylinders were not separated from full portable oxygen cylinders. This failure to segregate empty cylinders from full ones is a breach of the established protocols for oxygen storage, which require that empty cylinders be clearly marked and stored separately to avoid confusion. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The latch to the oxygen cabinet in the A0 clean utility room was replaced to ensure it would latch. The empty portable oxygen cylinders were separated from the full portable oxygen cylinders in the D1 oxygen storage room. D1 staff will be in-serviced on keeping full and empty oxygen cylinders separate. Maintenance will conduct quarterly inspections on the A0 clean utility room oxygen cabinet to ensure it latches properly. Maintenance will conduct monthly inspections on the D1 oxygen storage room to ensure the full and empty oxygen cylinders are separated. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.