Improper Segregation of Oxygen Cylinders in Storage
Penalty
Summary
The facility failed to ensure proper storage of nonflammable gas cylinders in accordance with NFPA 99, 11.6.5. During an observation on the south side of the building exterior, a not full oxygen cylinder was found mixed in with full oxygen cylinders in the designated full oxygen storage bin. This improper segregation of empty and full cylinders was directly observed and confirmed by the facility Maintenance Director at the time of the survey. The deficiency was identified based on the physical arrangement of the oxygen cylinders, where empty and full cylinders were not clearly separated as required. There is no mention of specific residents or staff being directly affected at the time of the observation, nor is there any reference to medical history or conditions of individuals involved. The report focuses solely on the improper storage practice and the failure to comply with established safety standards for gas cylinder management.
Plan Of Correction
The half-empty oxygen cylinder that was located/stored with the full cylinders was removed and put in the correct location on 5-8-2025. A one-time audit was completed on 5-20-25 by the Maintenance Director to ensure all oxygen cylinders were stored in the correct location. Education was provided to the Maintenance Staff on 5-20-25 by the Regional Maintenance Director as to the requirements of proper oxygen storage. A weekly audit x4 and then monthly x3 will be completed by the Maintenance Director or designee to ensure that oxygen storage containers are being stored properly. Audit findings will be presented to the facility QAPI committee and will only be discontinued with substantial compliance and with approval of the facility QAPI. The Administrator is responsible for achieving and sustaining compliance.