Failure to Post Required 'No Smoking' Signage in Oxygen Cylinder Storage Area
Penalty
Summary
Surveyors observed that a full H-sized oxygen cylinder was stored in the beauty salon, which is used as a temporary storage area when the salon is not in use. During the observation, it was noted that there was no 'No Smoking' sign posted in the area where the oxygen cylinder was stored, nor at the exterior entrances of the facility. The Chief Medical Officer (CMO) confirmed during the interview that the sign was missing and acknowledged the temporary storage practice in the salon. A review of the facility's policy and procedure titled 'Oxygen Safety' indicated that precautionary signs readable from five feet should be maintained on the door or gate where oxygen is used or stored. The lack of required signage in the area where the oxygen cylinder was stored was found to be out of compliance with NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.4. This deficiency was identified in one of five smoke compartments during the survey.
Plan Of Correction
Date of compliance: June 20, 2025 K923 Gas Equipment - Cylinder and Container Storage CFR(s): NFPA101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS posted "No Smoking signs" on the exterior of areas of the Oxygen Room and the Beauty Shop on 05/28/2025. (Exhibit #4 & Exhibit #5) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Oxygen Safety, ensuring that there are "No Smoking" signs in areas where oxygen cylinders were stored. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of rooms with oxygen use will be done once a month by MS for 3 months and kept in a log. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025