Improper Oxygen Cylinder Storage and Proximity to Combustibles
Penalty
Summary
The facility failed to comply with NFPA 99 requirements for the storage of nonflammable gases, specifically oxygen cylinders. During an observation, surveyors found that the oxygen storage closet in the main hall contained both full and non-full cylinders mixed together, rather than segregating empty cylinders from full ones as required. This was confirmed through an interview with the facility Maintenance Director at the time of observation. Additionally, the same oxygen storage closet was found to have combustibles stored within five feet of the oxygen cylinders, which is not permitted under the relevant fire safety standards. These deficiencies were identified during a survey and could potentially affect 17 occupants if the cylinders were needed during an emergency event. The report cites specific violations of NFPA 99 standards 11.6.5.2 and 11.3.2.3(2).
Plan Of Correction
K923 1. No residents were harmed as a result of this deficient practice. 2. The oxygen storage room has been appropriately organized and labeled in accordance with NFPA 99. All cardboard has been removed from the closet and signage has been introduced to keep the area clear. Proper storage racks and locations have clearly been labeled as to the placement of the oxygen containers. All clinical staff will be educated by 4/25/2025 regarding oxygen storage. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly audits of the oxygen room to ensure compliance. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.