Medical Gas System Inspection Documentation Lacking
Summary
The facility failed to maintain compliance with medical gas system requirements, as evidenced by the absence of documentation verifying that an annual inspection of the medical gas system was performed. This deficiency was identified during a document review and interview conducted on February 4, 2025, at 8:45 a.m. The Facility Administrator confirmed that the necessary documentation for the medical gas system inspection was not available at the time of the survey. This oversight affected the entire facility, as the required elements of the gas and vacuum systems inspection and testing were not documented as part of the maintenance program.
Plan Of Correction
908 main 1 1. A new vendor was contacted to complete the annual medical gas system inspection. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to ensure continued annual medical gas system inspections are completed. 908 main 2 1. A new vendor was contacted to complete the annual medical gas system inspection. 2. An ongoing audit is conducted and reviewed by the Director of maintenance or Designee to ensure continued annual medical gas system inspections are completed.
Penalty
The facility did not correct or document resolution of deficiencies found during the annual inspection of its medical gas and vacuum system, including leakage, loose outlets/inlets, a zone valve box needing cleaning, and missing caution labels, affecting all residents and smoke compartments.
Failure to Correct Deficiencies in Medical Gas and Vacuum System Maintenance
Penalty
Summary
The facility failed to maintain its Piped Medical Gas and Vacuum System as required by NFPA 99 standards. During a review of records and interviews with the Plant Operations Manager, it was found that the annual inspection and testing report for the medical gas and vacuum system identified several deficiencies, including leakage when an adapter was inserted, loose outlet/inlet, a zone valve box that required cleaning, and a missing caution label. The report did not include documentation of any corrective actions taken to address these issues. These deficiencies affected all 59 residents and all four smoke compartments in the facility. The lack of timely correction and documentation of the identified discrepancies in the medical gas and vacuum system constituted a failure to comply with required inspection, testing, and maintenance protocols. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Plan Of Correction
The contracted company repaired medical gas equipment according to the inspection report on 6/13/25. MONITORING: 1. The Plant Operations Manager or qualified designee will be maintaining the preventive maintenance of the piped gas and vacuum system. 2. The Director of Plant Operations will do random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
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