Unmarked Empty Oxygen Cylinders in Clean Supply Room
Summary
The facility failed to protect pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition. During an observation, four empty oxygen cylinders in the Clean Supply room were not marked as required. A Licensed Practical Nurse confirmed that three of the oxygen tanks in the unmarked rack were empty. This deficiency was identified during a recertification survey, and the facility was found to be non-compliant with the relevant regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were four (4) oxygen cylinders identified in the alleged deficient practice. B. The oxygen tank racks were inspected, and empty cylinders were moved to the empty cylinder rack at the time of the survey. C. Signage on the racks was updated to reflect the clean and empty racks and signs were secured to racks. 2. All residents with Oxygen Orders have the potential to be affected by this alleged deficient practice. B. All Current Skilled Nursing Facility staff will be educated on Compressed Gas. The Compressed Gas Training includes proper storage and placement of Oxygen Cylinders. C. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Day shift Charge Nurse will complete daily inspection of compressed gas racks on the Skilled Nursing Unit to ensure signage is in place and cylinders are suitably stored. The inspection will be documented on the Environment of Care log. 4. Scheduled [MEDICATION NAME] and Environment of Care rounds are in place to document compliance with compressed gas storage. B. Results of daily Compressed Gas Storage and monthly Environmental Rounds will be reviewed at the monthly Quality Assurance Performance Improvement Committee for further recommendations. 5. Associate Vice President of Facilities.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.