Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
Oxygen cylinders were observed stored within five feet of combustible stock items in the second floor clean linen room. This storage arrangement does not comply with NFPA 99 requirements, which mandate that oxidizing gases such as oxygen must be separated from combustibles by at least 20 feet, or 5 feet if the area is sprinklered, or stored in a compliant cabinet. The cylinders were not properly segregated from combustible materials, as required by the standard. The deficiency was identified during an observation conducted on April 14, 2025, at 10:35 AM, and was confirmed by the facility Maintenance Director at the time of the survey. The report notes that this practice could affect 76 of 175 facility residents in the event of a fire emergency, but does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K923 – Gas Equipment- Cylinder and Container Storage. 1. The facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 99. a. Oxygen cylinders within 5' was cleared of combustible stock items on the 2nd floor of new side clean linen room. 2. Maintenance Director and staff were educated on the proper Oxygen cylinder storage requirements. 3. To ensure continued compliance, Maintenance Director/designee will complete random audits 5x a week for 4 weeks to ensure oxygen rooms and linen closets have proper storage of oxygen cylinders. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.