Nursing Investigation Results -

Pennsylvania Department of Health
ARISTACARE AT MEADOW SPRINGS
Building Inspection Results

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ARISTACARE AT MEADOW SPRINGS
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ARISTACARE AT MEADOW SPRINGS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 20, 2019, at Aristacare at Meadow Springs, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 393602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2019, it was determined that Aristacare At Meadow Springs was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered above and below the suspended ceiling.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, documentation review and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility.

Findings Include:

1. Observation and document review on May 20, 2019, between 9:30 am and 2:00 pm, revealed the building was classified as a two story, unprotected ordinary construction, which is fully sprinklered above and below the suspended ceiling. The story height exceeds the maximum allowed for an unprotected ordinary construction type by on story.

Interview at the exit conference with the Administrator, Environmental Services Director, and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the building construction issue.





 Plan of Correction - To be completed: 07/14/2019

Facility requests an updated FSES to be conducted by the Department of Health according to 2012 Life Safety Code
NFPA 101 STANDARD Emergency Lighting:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire facility.

Findings include:

1. Review of documents on May 20, 2019 between 9:00 am and 11:00 am, revealed documentation was unavailable for the emergency back-up battery lighting fixture annual 90 minute testing.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on, confirmed the documents were not available.












 Plan of Correction - To be completed: 07/16/2019

90-minute testing of emergency back-up battery lighting will be completed initially and then annually. Audits will be completed by Maintenance department or designee. Results of audit will be reported through Safety Committee.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas, affecting one of seven smoke compartments within this facility.

Findings include:

1. Observation made on May 20, 2019, at 1:15 pm, revealed at the 1st floor NLC wing, the social service storage room double doors failed to close completely and positively latch into the frame.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the doors failed to latch.










 Plan of Correction - To be completed: 07/16/2019

Double doors were repaired during inspection. Audits to be completed by Maintenance department or designee for storage room doors to ensure doors close completely and positively latch into the frame initially and then quarterly for six months. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure kitchen fire suppression equipment was properly inspected and maintained, affecting one of seven smoke compartments of this component.

Findings include:

1. Observation made on May 20, 2019 at 1:35 pm, revealed the monthly required quick checks were last documented on the kitchen suppression system inspection tags on March 2019.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director, on May 20, 2019, at 2:45 pm, confirmed the missing monthly quick checks on the fire suppression inspection tags.






 Plan of Correction - To be completed: 07/16/2019

Outside agency inspects kitchen suppression system inspection every six months. Every other month Maintenance Department or other qualified designee will check kitchen suppression system.
Quarterly audits for six months will be conducted to ensure monthly inspection checks are completed and documented.
Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.
NFPA 101 STANDARD Smoke Detection:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on documentation review and interview, it was determined the facility failed to maintain required testing of smoke detectors, affecting the entire facility.

Findings include:

1. Review of documents on May 20, 2019, between 9:00 am and 11:00 am, revealed the facility failed to provide two year sensitivity testing documentation for smoke detectors.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the documentation was not available.











 Plan of Correction - To be completed: 07/16/2019


Sensitivity testing has been conducted every two years. Documentation has been obtained and within facility.
Facility set up automatic sensitivity reports to be sent every two years when testing is completed by outside company.
Audit to ensure documentation is available at facility will occur every two years. Results of audits will be reported through Safety Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain sprinkler system components in operable condition, affecting 1 of three levels.

Findings include:

1. Document review on May 20, 2019, between 9:00 am and 11:00 am, revealed the antifreeze loop in the kitchen failed testing, and was documented not to have an approved solution with an approved risk assessment.

Reference the 2011 edition of NFPA 25, 5.3.4.1 (a) and (b).

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the corrected documentation was not available.







 Plan of Correction - To be completed: 07/16/2019


11-Outside company inspected and replaced the antifreeze in the antifreeze loop in the kitchen. Outside agency will continue to inspect this on a routine basis. Audit will be conducted by Maintenance or designee to ensure compliance with the antifreeze loop in the kitchen. Audit will be conducted annually. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors free from impediments to closing and ensure positive latching with smoke tight resistance, affecting two of seven smoke compartments within this component.

Findings include:

1. Observation made on May 20, 2019, at 1:00 pm, revealed room 207 corridor door was blocked open by chair.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the door was impeded from closing.


2. Observation made on May 20, 2019, at 1:00 pm, revealed the 1st floor NLC wing linen closet corridor door by room 229, failed to close completely and positively latch into the frame.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed that door failed to positively latch.


3. Observation made on May 20, 2019, between 1:25 pm and 1:40 pm, revealed the following corridor doors would not resist the passage of smoke between the top of the door and frame:

a. 1:25 pm, room 202 corridor door;
b. 1:40 pm, room 151 corridor door.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the above stated doors would not resist the passage of smoke.
















 Plan of Correction - To be completed: 07/16/2019

Checking for any barriers to impeded resident doors from closing will be added to facility's 'Non-Clinical Rounds' which are completely weekly by management team or designee. Results of 'Non-Clinical Rounds" will be reported through QA Steering Committee.

Door hinge was repaired during time of inspection to ensure NLC wing linen closet closed completely and positively latched into the frame. All utility closets will be audited quarterly for six months. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.

Room 202 and 151 corridor doors were repaired during time of inspection. Audit will be conducted quarterly for six months to ensure all corridor doors resist the passage of smoke between the top of the door and frame. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain annual inspections of fire rated door openings, affecting the entire facility.

Findings include:

1. Document review on May 20, 2019, between 9:00 am and 11:00 am, revealed the facility was unable to provide annual fire rated door assemblies inspection and testing information.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the documentation was unavailable.












 Plan of Correction - To be completed: 07/16/2019

Annual fire rated door assemblies inspection and testing will be completed and each door will have their own separate documentation.

Audits to be completed yearly to ensure completion and separate documentation for each door. Result of audit will be tracked through Safety Committee.

.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance Pr:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0907

Based on observation and interview, it was determined the facility failed to maintain the integrity of the piped-in medical gas system, affecting the entire facility.

Findings include:

1. Document review on May 20, 2019, between 9:00 am and 11:00 am, revealed the facility failed to provide annual medical gas bulk oxygen system inspection documentation.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the documentation was unavailable.


2. Observation made on May 20, 2019, at 1:50 pm, revealed above the 1st floor smoke barrier doors by rooms 129 and 127, copper medical gas piping was in contact with armored cables.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed copper supply lines were in contact with a differing metal type.









 Plan of Correction - To be completed: 07/16/2019

Annual medical gas bulk oxygen system inspection was completed on May 8, 2018. Environmental Services Director explained to inspector that the inspection was scheduled on 5/29/19 which was then completed. Annual inspections will be scheduled annually to the exact date or prior. Audit to ensure this will be completed annually and tracked through Safety Committee.

Copper medical gas piping that was in contact with armored cables was fixed immediately during inspection.

Random audit will be performed by Maintenance department or designee to ensure cables are not in contact with medical gas piping. Audits will be conducted quarterly for 6 months. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.

NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems, affecting the entire facility.
Findings include:
1. Review of documentation on May 20, 2019, between 9:00 am to 11:00 am, revealed the required annual inspection of receptacles in patient care areas was not performed. Receptacle testing should include the following:

a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the test was not performed.












 Plan of Correction - To be completed: 07/16/2019

Annual inspection of receptables in patient care areas will be performed by Maintenance department or designee. Audit to ensure this will be completed annually. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were secured properly, affecting two of seven smoke compartments within this facility.

Findings include:

1. Observation made on May 20, 2019, between 1:30 pm and 2:20 pm, revealed the following locations had " E" size oxygen cylinders that were not properly supported in a cylinder stand or chart:

a. 1:30 pm, within front hall supervisor office across from conference room;
b. 2:10 pm, outside the oxygen storage area there were four "E" size tanks that;
c. 2:20 pm, within the maintenance shop (1) freestanding "E" size tank.

Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm , confirmed medical gas cylinders were not stored properly.









 Plan of Correction - To be completed: 07/16/2019

All oxygen tanks were removed and properly stored. In-service will be conducted to staff regarding the proper way to store a oxygen tank. Designee will audit facility to ensure there are no free-standing oxygen tanks. Quarterly audit will be completed for 6 months. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.


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