Improper Storage of Oxygen Equipment
Summary
The facility failed to comply with NFPA 99 requirements for the storage of nonflammable gases. During an observation, it was found that nine oxygen concentrators were stored less than five feet from oxygen cylinders in the designated Oxygen Room. NFPA 99 specifies that there must be at least a five-foot separation between combustibles or materials housed in the same area as oxygen cylinders, or appropriate fire-rated enclosures must be used. This deficiency was identified through direct observation and confirmed by both the Director of Maintenance and Security and the Maintenance Director during the survey. The improper storage arrangement could affect six occupants in the event of a fire, as noted in the report. The surveyors documented that the facility did not ensure the required separation between oxygen concentrators and oxygen cylinders, which is a direct violation of the cited code. No information was provided regarding the medical history or condition of the affected occupants at the time of the deficiency.
Penalty
Surveyors found that more than 12 E-sized oxygen cylinders, exceeding 300 cubic feet, were improperly stored in the basement activities room. The storage did not meet NFPA requirements for construction, ventilation, and separation, as confirmed by the maintenance supervisor.
Surveyors found that two nurse station closets used for oxygen storage were not properly designed or constructed for storing over 300 cubic feet of oxygen cylinders, and one cylinder was left unsecured. The maintenance supervisor confirmed these deficiencies during the survey.
Surveyors found two full oxygen cylinders unsecured in the oxygen storage room near the generator, in violation of NFPA gas equipment storage requirements. The maintenance supervisor confirmed the deficiency during the inspection.
Surveyors found that oxygen cylinders were not properly secured in a rack in one area, and empty cylinders were stored with full ones in two storage rooms. These deficiencies were confirmed by the administrator and maintenance supervisor.
Surveyors found that medical gas cylinders were improperly stored and identified on all four floors, with excessive numbers of tanks and freestanding cylinders in multiple oxygen closets. These practices did not meet NFPA requirements for gas cylinder storage, as confirmed by facility leadership during the exit interview.
A portable oxygen tank was found freestanding and not properly secured in a resident's room, in violation of NFPA 99 requirements for gas cylinder storage. The Maintenance Director indicated that a nurse likely left the tank unsecured while replacing it. This deficiency affected two residents in one smoke compartment.
Improper Oxygen Cylinder Storage Exceeding 300 Cubic Feet
Penalty
Summary
Surveyors observed that the facility failed to maintain proper oxygen cylinder storage on one of its building levels. Specifically, during an inspection of the basement activities room, it was found that the room contained more than 300 cubic feet of oxygen, with over 12 E-sized cylinders stored within the space. This storage arrangement did not comply with the requirements for oxygen storage as outlined by NFPA 101 and NFPA 99, which specify construction, ventilation, and separation standards for quantities exceeding 300 cubic feet. The maintenance supervisor confirmed during the interview that the observed storage practice constituted a deficiency. The report did not mention any specific residents or patient care areas directly affected at the time of the observation, nor did it provide details about any adverse events related to the deficiency. The focus of the deficiency was solely on the improper storage of oxygen cylinders in the basement activities room.
Plan Of Correction
The systematic change was removing the E-sized cylinders to make sure there were 12 or fewer in the basement activity room. The Director of Maintenance will monitor the basement activity room for appropriate storage of E-sized oxygen cylinders. The Director of Maintenance will report these findings to the Administrator and at the Monthly Quality Assurance meeting.
Oxygen Cylinder Storage Deficiencies in Nurse Station Closets
Penalty
Summary
Surveyors observed that the facility failed to maintain gas equipment requirements in two of three nurse station closets. Specifically, the north and east oxygen storage closets were not designed and constructed to accommodate storage of over 300 cubic feet of oxygen cylinders, as required by NFPA 101 and NFPA 99 standards. Additionally, in the east oxygen closet, one oxygen cylinder was found unsecured at the time of the survey. These deficiencies were confirmed during an interview with the maintenance supervisor, who acknowledged the issues with the storage closets and the unsecured cylinder. No information was provided regarding any residents directly involved or affected at the time of the deficiency.
Plan Of Correction
At the time of surveyor identification, the unsecured oxygen cylinder was secured and the facility's oxygen cylinders were rearranged in the designed oxygen storage closets throughout the facility to ensure that the East and North oxygen storage closets did not have over 300 cubic feet of oxygen cylinders stored. No further action is needed. All staff will be re-educated that the oxygen cylinders must be secured appropriately and that there cannot be more than 300 cubic feet of oxygen cylinders stored in any of the oxygen storage closets. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all the oxygen cylinders are secured appropriately and that none of the oxygen storage closets have over 300 cubic feet of oxygen cylinders stored. On identification, unsecured oxygen cylinders will be secured and if needed oxygen cylinders will be removed from storage closets to ensure that there is no more than 300 cubic feet of oxygen cylinders stored in any one oxygen storage closet.
Unsecured Oxygen Cylinders in Storage Room
Penalty
Summary
During an inspection, surveyors observed that the oxygen storage room, located near the generator, contained two full oxygen cylinders that were not properly secured. This observation was made on August 5, 2025, at 11:02 a.m. The facility is required to maintain gas equipment in accordance with NFPA 101 and NFPA 99 standards, which include securing cylinders to prevent them from falling or being damaged. The maintenance supervisor was present during the observation and confirmed that the two full cylinders were unsecured at the time of the survey. The deficiency was identified based on the direct observation of the unsecured cylinders in the designated storage area. No additional details regarding patient involvement or medical history were provided in the report.
Plan Of Correction
Education was provided to all staff regarding the requirements of storing gas equipment. The two unsecured tanks identified during survey were immediately placed in a secured storage holder at the time of survey. Ongoing compliance will be maintained by observations during daily rounding by the Environmental Service Supervisor or designee, 3 times weekly for 2 weeks, then once weekly for 1 month.
Improper Oxygen Cylinder Storage in Multiple Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain proper storage of oxygen cylinders in three separate storage areas. On the second floor, four oxygen cylinders were found in the RNAC office without being secured in a rack or similar device to prevent them from tipping over. Additionally, in the Siegert Hall O2 storage room on the second floor and the Buchman Hall O2 storage room on the first floor, empty or used oxygen bottles were stored in racks designated for full bottles. These deficiencies were confirmed during interviews with the administrator and maintenance supervisor. The observations indicated that the facility did not follow required protocols for segregating empty and full cylinders, nor did it ensure that cylinders were properly secured to prevent accidents. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
Oxygen cylinders immediately placed into oxygen holders. Empty/used bottles moved to storage in used oxygen cylinder rack. Education will be provided to staff to not place used oxygen cylinders in full oxygen cylinder rack. NHA or designee will audit oxygen cylinders for appropriately placed into oxygen holders and only full oxygen cylinders placed into full oxygen cylinder rack weekly x 4 then monthly until substantial compliance achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Improper Storage and Identification of Medical Gas Cylinders
Penalty
Summary
Surveyors observed that the facility failed to properly store and identify medical gas cylinders across all four floors. Specifically, on the fourth, third, and second floors, oxygen closets adjacent to rooms 4815, 3815, and 2815 each contained more than 12 tanks, with the third floor also having 2 freestanding cylinders. On the first floor, the oxygen closet in the service corridor contained approximately 50 stored cylinders and 15 freestanding cylinders. These storage practices did not comply with NFPA 101 and NFPA 99 requirements for gas cylinder storage, including limitations on the number of cylinders, proper enclosure, and segregation of full and empty cylinders. The improper storage was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The report does not mention any specific residents or patient conditions related to the deficiency, nor does it describe any immediate consequences resulting from the improper storage. The deficiency was based solely on the observed storage conditions and the facility's failure to meet regulatory standards for medical gas cylinder management.
Plan Of Correction
Oxygen storage capacity will be limited to 12 full tanks on the 2nd, 3rd, and 4th floors, and 50 full tanks on the 1st floor. Staff educated on storage capacity and that all tanks must be placed in holders and not free-standing. Nurses will audit at the beginning of each shift, and supervisors will perform random audits to monitor compliance.
Improper Storage of Portable Oxygen Cylinder
Penalty
Summary
A deficiency was identified when a portable oxygen tank was observed freestanding and not properly secured in Bedroom 18. This observation was made during a facility tour and interview with the Administrator and Maintenance Director. The oxygen tank was not chained or supported in a proper cylinder stand or cart, as required by NFPA 99, Health Care Facilities Code, 2012 Edition, section 11.6.2.3. The Maintenance Director stated that a nurse was likely replacing the oxygen tank and left the old one in the room. This incident affected two of 93 residents in one of four smoke compartments. The report specifically notes that the portable oxygen tank was not properly secured, which is a violation of the regulations for gas equipment cylinder and container storage. No additional details about the residents' medical history or condition at the time of the deficiency are provided in the report.
Plan Of Correction
K923 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Oxygen tank was removed from room 18 on 6/25/25 and replaced with an oxygen tank that was fully secured. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: DON and DSD audited all rooms within the facility and found no other freestanding oxygen tanks, no other residents were affected. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Administrator gave 1:1 inservice with Central supply coordinator (CSC) on 6/26/25. CSC will be auditing all rooms 2 x week to verify all oxygen tanks are properly stored in resident rooms and oxygen storage rooms. • How the facility plans to monitor its performance to make sure that solutions are sustained: Central supply coordinator will bring audit findings to monthly QA meeting until 3 consecutive months with no findings. • Include dates when corrective action will be completed: Completed 6/26/25
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
