Failure to Maintain Fire Resistance in Gas Cylinder Storage
Penalty
Summary
The facility failed to maintain the fire resistance of its gas cylinder storage, specifically affecting one of the three levels in the facility. During an observation on January 23, 2025, it was noted that the door to the Oxygen Storage Room, located on the first floor next to resident room 729, did not close and positively latch as required. This deficiency was identified based on both observation and interview. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. The failure of the door to close and latch properly compromises the safety standards set for gas cylinder storage, which are crucial for preventing potential hazards associated with oxidizing gases.
Plan Of Correction
1. The door to the oxygen storage room next to resident room 729 has been repaired to ensure it positively latches. 2. NHA/Designee will educate the maintenance director on the requirement for the oxygen storage room to positively latch and close. 3. The maintenance director/designee will audit the doors to the oxygen storage rooms in the facility to ensure they close. 4. The NHA/Designee will audit oxygen storage rooms weekly x4, then monthly x2 to ensure they positively latch and close. Report of audit will be reported in monthly QA meeting.