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F0695
D

Failure to Post Oxygen in Use Signage for Residents Receiving Oxygen Therapy

Manteca, California Survey Completed on 12-23-2025

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

The facility failed to ensure that supplemental oxygen was administered in accordance with professional standards of practice for two residents who were receiving oxygen therapy. Both residents had active physician orders for oxygen to be administered via nasal cannula as needed for shortness of breath or comfort, and both were observed receiving oxygen through concentrators in their rooms. However, during multiple observations, there was no 'Oxygen in Use' signage posted on the doorways of either resident's room, as required by facility policy and procedure. Interviews with nursing staff, including licensed nurses and certified nurse assistants, confirmed that the residents were receiving oxygen therapy and that the required signage was not posted. Staff members acknowledged the importance of posting 'Oxygen in Use' signs to alert staff, residents, and visitors to the presence of oxygen and to prevent fire hazards. The staff also confirmed that it was their responsibility to ensure the signage was in place whenever a resident was receiving oxygen therapy. A review of the facility's policy and procedure for oxygen administration, as well as interviews with the Director of Staff Development and the Assistant Director of Nursing, further confirmed that the expectation was for nursing staff to post the appropriate signage immediately upon initiation of oxygen therapy. The Assistant Director of Nursing acknowledged that the facility's policy was not followed in these instances, as the required signage was not posted for either resident while they were receiving oxygen.

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