Missing Precautionary Signage in Oxygen Storage Room
Penalty
Summary
The facility was found to be non-compliant with NFPA 99 and NFPA 101 standards regarding the storage of gas equipment, specifically oxygen cylinders. During a Life Safety Survey tour, it was observed that the Oxygen Storage Room by the Southwest Exit lacked the required precautionary signage. The sign was missing the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," which is a mandatory requirement for safety and compliance. The deficiency was identified during an inspection conducted at 2:30 pm on April 1, 2025, with the Maintenance Director present. The absence of the necessary signage was acknowledged by the Maintenance Director during the survey. This oversight indicates a failure to adhere to the safety protocols outlined in NFPA 99 and NFPA 101, which are designed to ensure the safe storage and handling of gas cylinders to prevent potential hazards. The issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The lack of proper signage in the oxygen storage area represents a significant oversight in maintaining the required safety standards for gas equipment storage, as stipulated by the relevant NFPA codes.
Plan Of Correction
K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 15/1/25 K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 5/1/25