Improper Storage of Oxygen Cylinder
Penalty
Summary
The facility was found to be non-compliant with the proper storage of medical gases, specifically oxygen cylinders. During an observation on April 15, 2025, at 12:20 p.m., it was noted that on the first floor, in the Med room across from the conference room, there was a free-standing oxygen cylinder. This indicates that the facility did not adhere to the required storage protocols for medical gases as outlined in NFPA 101 and NFPA 99 standards. The deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. The improper storage of the oxygen cylinder suggests a lapse in following the guidelines that require cylinders to be stored securely and in a manner that prevents potential hazards. The report does not mention any specific residents or staff being directly affected by this deficiency at the time of the observation.
Plan Of Correction
1.) Immediately upon observation on April 15, 2025 the one free standing oxygen cylinder on the first floor in the Med Room across from the conference room was immediately removed. 2.) The Maintenance Director and/or designee audited the number and location of oxygen tanks and confirmed they were being stored properly. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all oxygen cylinders held in a holder and not free standing. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit all oxygen tanks monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.