Improper Storage of Oxygen Cylinders
Penalty
Summary
During a Life Safety recertification survey, it was observed that the facility did not comply with NFPA 99 standards for the storage of oxygen cylinders. Specifically, in the Oxygen storage room located at the Loading Dock area, oxygen tanks were found to be co-mingled, with three empty e-size tanks stored in the same rack as full tanks. Additionally, there were no signs present in the Oxygen Storage Room to indicate where empty and full cylinders should be placed. This deficiency was confirmed through observation and an interview with the Director of Maintenance, who acknowledged the lack of signage and stated that signs would be posted.
Plan Of Correction
Plan of Correction: Approved April 26, 2025 I. Immediate Corrective actions taken: 1. The sign designating storage of empty and full oxygen tanks to proper areas was immediately securely reinstalled. 2. The empty tanks were relocated to the appropriate location. II. Identify other residents The facility conducted a review of all areas where oxygen is stored and determined no other areas out of compliance. Residents were at minimal risk due to this deficiency. III. Systemic changes 1) The facility reviewed and updated the oxygen storage and use policy and procedure to comply with the requirements set forth in NFPA 99. All staff will be in-serviced on the requirements set forth in NFPA 99 for the storage and use of oxygen and the updates to the facility policy and procedure. 2) The Director of Security has added the inspection of oxygen storage area to the daily log. 3) Any items found out of compliance shall be corrected at the time of discovery. IV. Q/A Monitoring 1) The Director of Security will conduct weekly QAPI audits over X 3 months to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Engineering/Director of Security