Improper Storage and Security of Gas Cylinders
Summary
Surveyors identified a deficiency in the storage of gas cylinders in one of seven smoke compartments. During an observation of the outside storage room, they found 38 cylinders stored without the required precautionary signage indicating oxidizing gas storage. The signage was also required to indicate the presence of oxidizing gases and to include the mandated wording, but this was not present. In addition, full and empty cylinders were observed to be comingled, rather than being segregated as required by NFPA 99. Adjacent to this storage area, surveyors observed 25 additional cylinders that were not properly secured from unauthorized use, and the facility did not have any means in place to prevent unauthorized access to these cylinders. During a concurrent staff interview, the Maintenance Director acknowledged these findings and stated that he was not aware of the requirements for gas cylinder storage. The surveyors cited these conditions as noncompliance with NFPA 101 and NFPA 99 standards for gas equipment and cylinder storage.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0923 and assure continued compliance, the following plan has been put in place. K0923 - Gas Cylinder Storage & Security Immediate Correction: All 38 cylinders in the storage room were segregated and labeled. The 25 cylinders located outside were moved to a secured, locked enclosure. Identification of Others: All medical gas storage areas were audited. Permanent "Full" and "Empty" signs and "No Smoking" signage were installed at all entrances. Systemic Changes: A lockable enclosure was established for outdoor storage with a new "Key Control" log. Staff were re-trained on Medical Gas Safety and the mandatory requirement for locked storage. Monitoring (QA): The Maintenance Director will perform daily rounds for 30 days, then weekly thereafter, to ensure segregation and security.Findings will be reviewed at monthly QAPI meetings.
Penalty
Surveyors found that oxygen cylinders in a storage area were labeled as "full" and "partial/empty" without a clear definition for "partial," leading to possible misplacement of nearly full cylinders in the empty section. A staff member confirmed confusion about the requirements, and the issue had the potential to affect multiple residents.
Improper Segregation of Oxygen Cylinders Due to Undefined Signage
Penalty
Summary
During a facility tour, surveyors observed that the oxygen storage area near room A-13 contained two signs labeled "full" and "partial/empty" for cylinder segregation. However, the facility had not defined what constituted a "partial" cylinder, which created the potential for cylinders that were nearly full to be placed in the empty section. This lack of clear definition and segregation did not meet the requirements outlined in NFPA 99-2012 Edition, Section 11.6.5.2, which mandates that empty and full cylinders must be segregated if stored within the same enclosure. An interview with a medical staff member confirmed the finding, as the staff member was unaware of the specific requirements and found the signage confusing. The deficiency was identified as having the potential to affect eight out of 46 residents, but no specific details about the residents' medical history or conditions at the time of the deficiency were provided in the report.
Plan Of Correction
K923 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to maintain oxygen storage signage near room A 13; empty oxygen bottles were labeled "partial/empty." Step 1: Maintenance Director corrected the signage on 6-6-25 with a sign that reads "Empty." Step 2: All residents that utilize oxygen were assessed for proper storage and placement of oxygen tanks by 7/15/25. Step 3: LNHA educated all clinical staff on appropriate signage for Oxygen room 7/15/25. New hires are educated upon orientation. Step 4: LNHA/designee to monitor for continued compliance will audit oxygen room signage weekly x4 then monthly x2. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.
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