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K0923
D

Improper Storage of Oxygen Cylinders

Pomona, California Survey Completed on 05-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to maintain proper separation between full and empty pressurized oxygen cylinders in accordance with NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.6.5.2. During an inspection of the Oxygen Storage Room, one full oxygen cylinder was found stored with empty cylinders under the 'EMPTY' indicator sign, and two empty cylinders were found stored with full cylinders under the 'FULL' indicator sign. The staff member present confirmed that full and empty oxygen cylinders should be stored separately. A review of the facility's policies and procedures revealed that hazardous areas, devices, and equipment are to be identified and addressed to ensure resident safety and compliance with regulations. The maintenance policy also requires the building to be maintained in compliance with current laws and free from hazards. Despite these policies, the improper storage of oxygen cylinders was observed, indicating a failure to follow established procedures for hazardous materials management.

Plan Of Correction

K 923 Immediate Corrective Action: The MS immediately removed the full oxygen cylinder that was stored in the "EMPTY" indicator side, to the "FULL" indicator side. The two empty oxygen cylinders that were stored in the "FULL" indicator side were moved to the "EMPTY" indicator side. Identifying of Others: All full and empty oxygen cylinders were stored in their appropriate indicated sign. No other oxygen cylinders had this deficient practice. Measures in place: On 5/22/25 the DSD in serviced the licensed staff on the storing of oxygen. The "FULL" indicator of oxygen needs to be stored on the right side as it indicates and the "EMPTY" needs to be stored on the left side as indicated. Monitoring: The MS and the MS assistant, when doing their daily rounds x 3 months, will ensure the oxygen storage room is being maintained with the full and empty oxygen cylinders separated and as indicated. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completion date: 5/22/25

See complete original report
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