Improper Oxygen Cylinder Storage Exceeding 300 Cubic Feet
Penalty
Summary
Surveyors observed that the facility failed to maintain proper oxygen cylinder storage on one of its building levels. Specifically, during an inspection of the basement activities room, it was found that the room contained more than 300 cubic feet of oxygen, with over 12 E-sized cylinders stored within the space. This storage arrangement did not comply with the requirements for oxygen storage as outlined by NFPA 101 and NFPA 99, which specify construction, ventilation, and separation standards for quantities exceeding 300 cubic feet. The maintenance supervisor confirmed during the interview that the observed storage practice constituted a deficiency. The report did not mention any specific residents or patient care areas directly affected at the time of the observation, nor did it provide details about any adverse events related to the deficiency. The focus of the deficiency was solely on the improper storage of oxygen cylinders in the basement activities room.
Plan Of Correction
The systematic change was removing the E-sized cylinders to make sure there were 12 or fewer in the basement activity room. The Director of Maintenance will monitor the basement activity room for appropriate storage of E-sized oxygen cylinders. The Director of Maintenance will report these findings to the Administrator and at the Monthly Quality Assurance meeting.