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)
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Observations: Name: MAIN BUILDING 01 (A,B,C, WINGS) - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were separated on one of two levels of the facility.
Findings Include:
Observation made on May 29, 2025, at 12:45 p.m., revealed, on the second floor, Oxygen Storage room had full oxygen cylinders mixed in with empty oxygen cylinders.
Exit interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the mixed cylinders.
| | Plan of Correction - To be completed: 07/09/2025
O2 Cylinders were separated by empty and full. Maintenance will conduct random weekly audits to ensure 02 cylinders are not mixed. Maintenance will educate staff regarding the required separation of O2 tanks. Signage identifying full and empty oxygen cylinders will be installed in the room. Findings will be reported to quarterly qapi/safety committee meetings.
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