Improper Storage of Medical Gas Cylinders
Summary
The facility failed to maintain proper storage for medical gas cylinders, as observed during a tour conducted on March 3, 2025. The deficiency was identified in the 1st floor clean utility and soiled utility rooms, where medical gas is stored. The doors to these rooms, which open to the corridor, were found to be unable to close, latch, and lock, thereby failing to ensure unauthorized entry prevention. This issue was confirmed through an interview with the RMS conducted concurrently with the observations. The report highlights the importance of proper storage and handling of compressed gases for the safety of staff, patients, and visitors within the facility. The facility's failure to comply with NFPA 99 and NFPA 101 standards, specifically regarding the security and proper enclosure of medical gas storage areas, constitutes a significant safety concern. The deficiency was documented based on the observations and interviews conducted during the facility tour.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 3/7/25, 1st floor clean utility and soiled utility room doors were corrected with new lock and latch to ensure proper closure. On 3/7/25, 1st floor clean utility and soiled utility room door keypads were added to ensure authorized entry. On 3/4/25, maintenance staff was educated on the components of K923 Gas Equipment, Cylinder and Container Storage with an emphasis to maintain proper storage for medical gas cylinders by the Administrator/Designee. Any newly hired Maintenance Director will be educated on maintaining proper storage for medical gas cylinders by the Administrator/Designee on the components of K923 Gas Equipment, Cylinder and Container Storage. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/designee to conduct door and storage audits 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure proper storage for medical gas cylinders. The findings of these quality monitoring audits to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. 3/11/25 (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur,
Penalty
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors observed that more than 12 "E" oxygen cylinders (18 total) were stored in a sprinkler room within five feet of combustible materials, contrary to NFPA 99 requirements for gas equipment cylinder storage. The Maintenance Director confirmed this storage practice during the survey. This noncompliance with NFPA 99 sections 11.3.1–11.3.3 was cited as a deficiency affecting all occupants in the event of a fire or other emergency.
Surveyors found that an oxygen storage room on the second floor lacked the required precautionary signage stating, "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as mandated for gas cylinder storage areas. This deficiency was confirmed by facility leadership during the initial survey and again during a subsequent revisit, when the same room was still missing the required sign.
Surveyors found that oxygen cylinders were stored in crash cart rooms in two separate cores without the required precautionary signage on the doors indicating oxidizing gas storage and no smoking. Observations in two smoke compartments showed oxygen cylinders present in the 3 East and 2 East core crash cart rooms, yet the doors lacked the mandated "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" signage. The facility administrator and maintenance leadership confirmed that the proper oxygen storage signs were not posted on these doors.
Surveyors found that oxygen cylinders stored within first- and second-floor nurses' stations were placed less than five feet from electrical receptacles and combustible materials, in violation of NFPA 99/101 requirements for separation of oxidizing gases from combustibles and ignition sources. The Administrator and Maintenance Director confirmed during interview that the cylinders were improperly stored in proximity to these combustible and ignition sources.
Surveyors found that gas cylinders were improperly stored and unsecured, with 38 cylinders in an outside storage room lacking the required oxidizing gas signage and with full and empty cylinders comingled, and an additional 25 cylinders stored adjacent to this area without any means to prevent unauthorized access. During an interview, the Maintenance Director acknowledged the issues and reported being unaware of the specific NFPA 99 storage requirements.
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
The deficiency involves improper storage of medical gas cylinders, specifically more than 12 "E" oxygen tanks, in violation of NFPA 99 requirements. During an observation at 4:30 PM with the Maintenance Director, surveyors noted that 18 "E" tanks were being stored in a sprinkler room. These cylinders were located within five feet of combustible materials, contrary to NFPA 99 (2012 and 2021 editions), which requires that oxidizing gas cylinders in quantities greater than 300 cubic feet be separated from combustibles by at least 20 feet (or 5 feet if the area is sprinklered) or stored in an appropriately rated noncombustible cabinet. The report states that the storage arrangement did not comply with NFPA 99 sections 11.3.1, 11.3.2, and 11.3.3, which govern gas equipment cylinder and container storage, including separation from combustibles. The Maintenance Director acknowledged during the survey that 18 "E" tanks were stored in the sprinkler room within five feet of combustibles. The deficiency is cited as affecting all occupants in the facility in the event of a fire or other emergency, and no additional resident-specific clinical details are provided in the report.
Plan Of Correction
tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on . [R] tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Post Required Oxygen Storage Room Cautionary Signage
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During an observation on the second floor, they found that the Oxygen Storage Room did not have the required precautionary signage on the door. Specifically, the room lacked a sign readable from 5 feet that stated: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as required for oxygen cylinder storage areas. This absence was directly observed by surveyors during the inspection. In an exit interview conducted with the Administrator and the Maintenance Director following the initial observation, facility leadership confirmed the lack of required signage. During a subsequent onsite revisit, surveyors again observed that the same second-floor Oxygen Storage Room still lacked the mandated cautionary sign. In a second exit interview with the Administrator and a Maintenance Representative, they again confirmed that the signage remained absent at the time of the revisit.
Plan Of Correction
1. The facility immediately purchased and installed the required signage at the Oxygen Storage Room on the second floor. The signage was updated to include "Oxygen Storage No Smoking" in accordance with NFPA 99 requirements for compressed gas storage areas. 2. All residents have the potential to be affected by this issue. 3. The Director of Maintenance and facility leadership were in-serviced on the requirements for proper labeling and signage of medical gas storage areas, including oxygen storage rooms, in accordance with NFPA 99 and CMS Life Safety Code requirements. 4. The Director of Maintenance or designee will conduct routine environmental rounds to ensure all medical gas storage areas are properly labeled and compliant with NFPA 99 signage requirements. Audits will be conducted monthly for three months, with immediate correction of any identified deficiencies. Findings will be documented and reported to the Quality Assurance and Performance Improvement (QAPI) Committee as appropriate.
Failure to Post Required Oxygen Storage Signage in Crash Cart Rooms
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. The code requires that storage rooms or areas containing oxidizing gases, such as oxygen cylinders, have precautionary signage on each door or gate that is readable from 5 feet and includes, at a minimum, the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." During the survey, the facility was evaluated for compliance with these standards, which apply to various quantities of stored gas and require proper construction, separation from combustibles, and appropriate labeling of storage locations. On the survey date, observations showed that oxygen cylinders were stored in two separate crash cart rooms, one in the 3 East core and one in the 2 East core, without any signage indicating oxygen storage on the doors. These observations occurred at 10:13 a.m. in the 3 East core crash cart room and at 11:03 a.m. in the 2 East core crash cart room. The Facility Administrator and Director of Maintenance confirmed during an interview that the doors to these rooms did not have the required oxygen storage signage. The deficiency affected two of fifteen smoke compartments in the facility.
Plan Of Correction
1. On April 27, 2026, propersignage for oxygen was placed onthe 3 east crash cart room and the 2east crash cart room. 2. On April 27th, 2026 the Directorof Maintenance conducted afacility-wide inspection of all oxygencylinder storage locations and crashcart rooms to verify that requiredoxygen signage was present and nooxygen cylinders were improperlystored. 3. The maintenance staff wereeducated to ensure that propersignage for oxygen storage is postedfor all rooms where oxygen is stored. 4. The Director of Maintenance ordesignee will conduct weekly auditsx4 weeks and monthly after for 3months of oxygen storage areas toverify proper signage. Auditfindings will be documented andreviewed during the facility'smonthly QAPI meetings
Improper Oxygen Cylinder Storage Near Combustibles and Electrical Receptacles
Penalty
Summary
Surveyors identified a deficiency related to improper storage of oxygen cylinders in the facility. During an observation conducted on the first and second floors between 10:30 a.m. and 12:15 p.m., oxygen cylinders were found stored within the nurses' stations. These cylinders were located less than five feet from electrical receptacles and combustible materials, contrary to NFPA 99 and NFPA 101 requirements for separation of oxidizing gases from combustibles and ignition sources. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the oxygen cylinders were stored less than five feet from combustible and ignition sources. The report does not describe any specific residents, clinical conditions, or adverse events, but focuses on the environmental and storage practices for gas equipment within the nurses' stations on two of the three levels surveyed.
Plan Of Correction
Maintenance staff removed the oxygen cylinders from the first and second floor nurses stations. Nursing posted signage no oxygen cylinders are to be stored at the first and second floor nurses station to ensure cylinders are distanced from combustible materials/ignition sources. Maintenance will complete random monthly audits on first and second floor nurses stations to ensure oxygen is not being stored in those areas and present finding to the Quality Council monthly for review to maintain compliance.
Improper Storage and Security of Gas Cylinders
Penalty
Summary
Surveyors identified a deficiency in the storage of gas cylinders in one of seven smoke compartments. During an observation of the outside storage room, they found 38 cylinders stored without the required precautionary signage indicating oxidizing gas storage. The signage was also required to indicate the presence of oxidizing gases and to include the mandated wording, but this was not present. In addition, full and empty cylinders were observed to be comingled, rather than being segregated as required by NFPA 99. Adjacent to this storage area, surveyors observed 25 additional cylinders that were not properly secured from unauthorized use, and the facility did not have any means in place to prevent unauthorized access to these cylinders. During a concurrent staff interview, the Maintenance Director acknowledged these findings and stated that he was not aware of the requirements for gas cylinder storage. The surveyors cited these conditions as noncompliance with NFPA 101 and NFPA 99 standards for gas equipment and cylinder storage.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0923 and assure continued compliance, the following plan has been put in place. K0923 - Gas Cylinder Storage & Security Immediate Correction: All 38 cylinders in the storage room were segregated and labeled. The 25 cylinders located outside were moved to a secured, locked enclosure. Identification of Others: All medical gas storage areas were audited. Permanent "Full" and "Empty" signs and "No Smoking" signage were installed at all entrances. Systemic Changes: A lockable enclosure was established for outdoor storage with a new "Key Control" log. Staff were re-trained on Medical Gas Safety and the mandatory requirement for locked storage. Monitoring (QA): The Maintenance Director will perform daily rounds for 30 days, then weekly thereafter, to ensure segregation and security.Findings will be reviewed at monthly QAPI meetings.
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