Deficiency in Securing Oxygen Cylinders and Electrical Safety
Summary
The facility was found to have deficiencies related to the handling and securing of portable oxygen cylinders. During an observation on April 8, 2025, between 10:50 AM and 11:27 AM, it was noted that portable oxygen cylinders were unsecured in various locations across the facility. Specifically, one cylinder was found unsecured in the 4th floor Therapy Room, two cylinders in the 4th floor Medicine Room, one cylinder in the 3rd floor Medicine Room, two cylinders in the 2nd floor Director of Nursing Office, and one cylinder in the 2nd floor Medicine Room. An interview with the Maintenance Director confirmed that these cylinders were not secured, which is a violation of the NFPA 99 standards for handling oxygen equipment. Additionally, a receptacle multiplier was observed supplying power to a radio and a camera by the Lobby fireplace, which was also confirmed by the Maintenance Director.
Plan Of Correction
1. The oxygen cylinders that were unsecured were secured and placed appropriately in racks on 04-08-2025. 2. Maintenance Director and Director of Nursing, or designees, will educate maintenance and nursing staff on properly securing oxygen cylinders. Maintenance Director will audit weekly for two weeks, then monthly to ensure that oxygen cylinders are properly secured in racks. Results of audits will be submitted to monthly QAPI for review and recommendations.
Penalty
An oxygen cylinder in a transport cart was found unsecured during a facility tour, violating NFPA 99 standards. The Maintenance Director and Regional Maintenance Consultant acknowledged the deficiency, which was reviewed with the Administrator during the exit conference. Photographic evidence was obtained.
The facility failed to secure portable oxygen cylinders as required by NFPA 99 standards. Five unsecured 'E' size portable oxygen cylinders were observed outside the Oxygen Storage Room on the first floor. The Director of Maintenance confirmed the unsecured state of the cylinders, affecting one of the seven smoke compartments.
Unsecured Oxygen Cylinder in Transport Cart
Penalty
Summary
The facility failed to manage an oxygen cylinder in accordance with NFPA 99 standards. During a facility tour conducted by the Maintenance Director and the Regional Maintenance Consultant, it was observed that an e-size oxygen cylinder in a transport cart was unsecured. The cylinder was not properly secured to the cart, which is a violation of the safety standards outlined in NFPA 99. The observations were confirmed through an interview with the Maintenance Director and the Regional Maintenance Consultant, who acknowledged the findings. These findings were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the unsecured oxygen cylinder, further substantiating the deficiency.
Plan Of Correction
1. The e-size oxygen cylinder in transport cart was secured on 03/31/2025 by the Maintenance Director. 2. The Maintenance Director conducted quality assurance check on e-size oxygen cylinders in transport carts to ensure they were secured on 4/1/2025 and no additional findings notes. 3. Education was provided to facility staff on securing e-size oxygen cylinder in transport securely by the NHA or designee by 4/25/2025. The Maintenance Director, or designee, will conduct weekly for 12 weeks audit on 5 random e-size oxygen cylinders in transport carts to ensure they are secured. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Unsecured Portable Oxygen Cylinders
Penalty
Summary
The facility failed to secure portable oxygen cylinders, which is a requirement under NFPA 99 standards for handling gas equipment. During an observation on February 12, 2025, at 2:00 PM, five unsecured 'E' size portable oxygen cylinders were found outside the Oxygen Storage Room, within a first-floor room by SC-5. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the unsecured state of the oxygen cylinders. This issue affected one of the seven smoke compartments within the component.
Plan Of Correction
1. Cylinders were placed back into proper storage area after observation. 2. Facility will provide re-education to staff regarding appropriate storage of oxygen cylinders. 3. Maintenance director/designee will complete audits of storage areas monthly to ensure they are properly stored. Audits will be reviewed at QAPI to ensure compliance.
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