Failure to Post Oxygen Signage in Resident Room
Penalty
Summary
The facility failed to post required cautionary and safety signage indicating the presence of oxygen in a resident's room, as mandated by facility policy. Observation on 12/29/2025 revealed a portable oxygen tank in the resident's room with no oxygen tubing attached and no signage posted on or around the door. Interviews with nursing staff and administration confirmed that facility policy requires an 'Oxygen in Use' sign to be posted whenever oxygen is present in a room, regardless of whether it is actively in use or scheduled. Record review of the resident's care plan and physician orders did not reflect an active order for oxygen therapy, but the oxygen tank was still present in the room without appropriate signage. The resident involved was a male with severe cognitive impairment, multiple physical disabilities, and a history of falls, who was dependent on staff for self-care and mobility. Staff interviews indicated that all staff members are responsible for ensuring the signage is posted, but this was not done in this instance. Facility policies reviewed included requirements for clear identification of oxygen storage areas and the posting of 'No Smoking' and 'Oxygen in Use' signs, which were not followed at the time of the survey.