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 maintain oxygen storage rooms, affecting one of two levels in the facility.
Findings include:
Observation on March 30, 2026, at 10:05 a.m., revealed, on the second floor, the Oxygen Storage Room lacked signage stating:CAUTION: OXIDIZING GAS(ES) STORED WITHINNO SMOKING
Exit interview with the Administrator and the Maintenance Director on March 30, 2026, at 10:30 a.m., confirmed the lack of signage.
------------------------------------------------------------------------
Observations during an onsite Revisit conducted on April 28, 2026, between 8:00 am and 9:30 a.m., determined the following:
Item #1- Not Completed. On the second floor, Oxygen Storage Room lacked signage stating:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING
Exit interview with the Administrator and Maintenance Representative on April 28, 2026, at 9:30 a.m., confirmed the lack of signage.
| | Plan of Correction - To be completed: 05/05/2026
1. The facility immediately purchased and installed the required signage at the Oxygen Storage Room on the second floor. The signage was updated to include "Oxygen Storage No Smoking" in accordance with NFPA 99 requirements for compressed gas storage areas.
2. All residents have the potential to be affected by this issue.
3. The Director of Maintenance and facility leadership were in-serviced on the requirements for proper labeling and signage of medical gas storage areas, including oxygen storage rooms, in accordance with NFPA 99 and CMS Life Safety Code requirements.
4. The Director of Maintenance or designee will conduct routine environmental rounds to ensure all medical gas storage areas are properly labeled and compliant with NFPA 99 signage requirements. Audits will be conducted monthly for three months, with immediate correction of any identified deficiencies. Findings will be documented and reported to the Quality Assurance and Performance Improvement (QAPI) Committee as appropriate.
|
|
