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NY State Tag
D

Improper Storage of Oxygen Cylinders

Pittsford, New York Survey Completed on 02-19-2025

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 properly maintain medical gases in compliance with the 2012 edition of NFPA 99, Standard for Health Care Facilities. During a Life Safety Code Survey, it was observed that oxygen cylinders were stored in an outdoor area unprotected from inclement weather. Specifically, a large wheeled green metal rack holding 77 full E-size oxygen cylinders was found with snow accumulation and melting snow on some of the tanks. This rack was only covered on the top and open on all four sides. Additionally, an uncovered wheeled cart holding 10 full E-size oxygen cylinders was located next to the larger rack. The Director of Facilities acknowledged the issue and suggested that the tanks could be moved to a lean-to area or an enclosure. The NFPA 99 requires that storage locations for medical gases be outdoors in an enclosure or within an enclosed interior space, protected against weather extremes, and secured against unauthorized entry.

Plan Of Correction

Plan of Correction: Approved March 5, 2025 1. Facility ordered and will install an enclosure that meets NFPA 99 standards. Facility immediately ensured all gas cylinders are stored upright and were properly secured with chains and straps to prevent tipping. “No smoking” and “Flammable gas” signs have also been placed in visible locations around the storage area. Also, the facility clearly labeled full and empty cylinders to ensure separation. 2. A facility-wide review was conducted to ensure all O2 cylinders throughout the facility were stored properly. The facility also implements a weekly inspection checklist for gas storage compliance and documentation. 3. All pertinent facility staff will be educated on the proper use, transport, and storage of full and empty O2 cylinders. 4. The facility will conduct a monthly audit of O2-cylinder storage for three months. These results will be presented to the QA committee for review. The committee will determine the needed frequency of the audit thereafter. Responsible Party: Director of Facilities

See complete original report
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