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K0923
D

Improper Storage of Oxygen Cylinder in Facility Storage Room

Santa Paula, California Survey Completed on 04-22-2025

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

During a facility tour, surveyors observed that an 'E' type oxygen cylinder was not supported in a proper cylinder stand or cart, but was instead freestanding in the oxygen storage room. The aggregate volume of oxygen stored in the room exceeded 300 cubic feet. According to NFPA 99, freestanding cylinders must be properly chained or supported to prevent abnormal mechanical shock that could damage the cylinder, valve, or safety device. The Maintenance Supervisor confirmed the observation and noted that the cylinder may have belonged to an outside agency. The deficiency affected 38 of 79 residents in one of three smoke compartments. The report specifically cites the failure to maintain oxygen cylinders in accordance with required safety standards, as the cylinder was not properly secured. No additional information about the medical history or condition of the residents involved is provided in the report.

Plan Of Correction

K923 CORRECTIVE ACTION Stand alone oxygen tanks were immediately removed from affected locations by maintenance staff and properly placed in storage dedicated oxygen storage location stands. IDENTIFICATION OF OTHERS Maintenance staff immediately completed a facility-wide sweep to ensure that no other areas and residents were affected by this deficient practice. MEASURES TO PREVENT RECURRENCE: DSD/Designee provided facility staff with an inserviced regarding our oxygen safety policies including proper handling and safe storage of portable oxygen tanks. SEE EXHIBIT - H MONITORING PROCESS: Administrator/Designee will assign the safety committee panel members designated areas of the building to inspect for inappropriately placed or stored oxygen tanks and report findings during our monthly safety committee meeting for monitoring, improvement, and implement strategies for compliance.

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