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F0689
D

Unsecured Oxygen Tank Found in Resident Room

Two Harbors, Minnesota Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when an oxygen tank was found free standing in a resident's room rather than being secured in a designated holder. The resident involved had chronic obstructive pulmonary disease (COPD), depression, and anxiety, and required substantial to maximum assistance with activities of daily living. The resident was observed using oxygen via nasal cannula as ordered. During an observation, one oxygen tank was noted to be free standing near a stationary holder that contained five other secured tanks. Multiple staff members, including the maintenance director, associate administrator, LPN, and DON, confirmed that oxygen tanks should always be secured for safety reasons. The maintenance director and DON both stated that an unsecured tank could become a hazard if knocked over. Staff also verified that they receive training on oxygen safety as part of hazard training. When requested, the facility was unable to provide a policy on oxygen storage.

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