Failure to Post Required Oxygen Storage Signage in Crash Cart Rooms
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. The code requires that storage rooms or areas containing oxidizing gases, such as oxygen cylinders, have precautionary signage on each door or gate that is readable from 5 feet and includes, at a minimum, the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." During the survey, the facility was evaluated for compliance with these standards, which apply to various quantities of stored gas and require proper construction, separation from combustibles, and appropriate labeling of storage locations. On the survey date, observations showed that oxygen cylinders were stored in two separate crash cart rooms, one in the 3 East core and one in the 2 East core, without any signage indicating oxygen storage on the doors. These observations occurred at 10:13 a.m. in the 3 East core crash cart room and at 11:03 a.m. in the 2 East core crash cart room. The Facility Administrator and Director of Maintenance confirmed during an interview that the doors to these rooms did not have the required oxygen storage signage. The deficiency affected two of fifteen smoke compartments in the facility.
Plan Of Correction
1. On April 27, 2026, propersignage for oxygen was placed onthe 3 east crash cart room and the 2east crash cart room. 2. On April 27th, 2026 the Directorof Maintenance conducted afacility-wide inspection of all oxygencylinder storage locations and crashcart rooms to verify that requiredoxygen signage was present and nooxygen cylinders were improperlystored. 3. The maintenance staff wereeducated to ensure that propersignage for oxygen storage is postedfor all rooms where oxygen is stored. 4. The Director of Maintenance ordesignee will conduct weekly auditsx4 weeks and monthly after for 3months of oxygen storage areas toverify proper signage. Auditfindings will be documented andreviewed during the facility'smonthly QAPI meetings
Penalty
Surveyors found that oxygen cylinders in a storage area were labeled as "full" and "partial/empty" without a clear definition for "partial," leading to possible misplacement of nearly full cylinders in the empty section. A staff member confirmed confusion about the requirements, and the issue had the potential to affect multiple residents.
Improper Segregation of Oxygen Cylinders Due to Undefined Signage
Penalty
Summary
During a facility tour, surveyors observed that the oxygen storage area near room A-13 contained two signs labeled "full" and "partial/empty" for cylinder segregation. However, the facility had not defined what constituted a "partial" cylinder, which created the potential for cylinders that were nearly full to be placed in the empty section. This lack of clear definition and segregation did not meet the requirements outlined in NFPA 99-2012 Edition, Section 11.6.5.2, which mandates that empty and full cylinders must be segregated if stored within the same enclosure. An interview with a medical staff member confirmed the finding, as the staff member was unaware of the specific requirements and found the signage confusing. The deficiency was identified as having the potential to affect eight out of 46 residents, but no specific details about the residents' medical history or conditions at the time of the deficiency were provided in the report.
Plan Of Correction
K923 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to maintain oxygen storage signage near room A 13; empty oxygen bottles were labeled "partial/empty." Step 1: Maintenance Director corrected the signage on 6-6-25 with a sign that reads "Empty." Step 2: All residents that utilize oxygen were assessed for proper storage and placement of oxygen tanks by 7/15/25. Step 3: LNHA educated all clinical staff on appropriate signage for Oxygen room 7/15/25. New hires are educated upon orientation. Step 4: LNHA/designee to monitor for continued compliance will audit oxygen room signage weekly x4 then monthly x2. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.
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