Davita Delta Sierra Dialysis Center

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 48445 Based on interview and record review, the facility failed to develop monthly plan of care (POC) for two of five patients (Patient 1 and Patient 2) as required by the regulations for unstable patients. This failure had the potential to decrease the facility’s capability in addressing patients’ concerns and determining if these concerns were resolved. Findings: During a review of five randomly selected patients’ POCs, monthly POCs were not developed for the following two unstable patients: - Patient 1 was deemed unstable for deterioration of health status and the last POC was finalized on 9/9/25. There were no POC developed thereafter for Patient 1; and, - Patient 2 was deemed unstable for deterioration of health status and the POC was finalized on 9/9/25. There was no POC developed thereafter for Patient 2. During a concurrent interview and record review on 10/31/25 at 1:52 p.m. with the Manager of Clinical Services (MCS), the MCS confirmed Patient 1 and Patient 2 were both deemed unstable and required monthly development of POCs. The MCS confirmed that both Patient 1 and Patient 2’s last POCs were completed on 9/9/25 and there were no POCs developed for Patient 1 and Patient 2 thereafter. The MCS stated that the expectation was for the facility to complete all POCs and make sure POCs and assessments were addressed timely. The MCS further stated that if a patient was deemed unstable, the facility have to address the issue on a monthly basis to determine if the patient was still unstable. During an interview on 10/31/25 at 2:33 p.m. with the Facility Administrator (FA), the FA confirmed there were no POCs developed for Patient 1 and Patient 2 for October 2025. The FA stated attempts were made to contact the physician to complete the POCs but unable to get a hold of the physician even via telephone, and that the Medical Director was aware of the situation. The FA stated that for unstable patients, it was important to have the POC reviewed monthly to make sure that the plans for the patient was being addressed. During a review of the facility’s policy and procedure (P&P) titled “CONTINUOUS QUALITY IMPROVEMENT PROGRAM,” revised 4/2021, the P&P indicated, “ ...4. The Facility Medical Director is responsible for verifying the execution as well as the participation in the Quality Improvement Program including implementation, continuous monitoring, development of action plans and program evaluation ...” During a review of the facility’s P&P titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE,” revised 10/2024, the P&P indicated, “ ...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: ...At least monthly for unstable patients including, but not limited to, patients with the following: ...Marked deterioration in health status ...Monthly (unstable patients) ...Monthly until patient is determined by interdisciplinary team to be stable ...””

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 48445 Based on interview and record review, the facility failed to evaluate the psychosocial needs of three of seven sampled patients (Patient 1, Patient 2, and Patient 3) when there was no social worker present during the Interdisciplinary Team (IDT) Meetings and no social worker to develop Plan of Care (POC). This failure resulted in incomplete POC and the potential for unmet psychosocial needs. Findings: During a review of Patient 1’s admission records, the records indicated Patient 1 was admitted to the facility in May 2025 with diagnosis of End-Stage Renal Disease (ESRD - irreversible kidney failure). During an interview on 8/13/25 at 12:22 p.m. with the Facility Administrator (FA), Patient 1’s plan of care was requested. The FA stated Patient 1 was newly admitted and did not have a POC yet and that the facility was still working on the 30-day assessment. During a review of Patient 2’s POC, dated 6/11/25, the POC indicated Patient 2 was deemed unstable due to deterioration of health status. The POC was finalized on 6/11/25 and did not indicate that a social worker was present during the IDT meeting. Patient 2 did not have POC developed for July and August 2025. During a review of Patient 3’s POC, dated 6/11/25, the POC indicated Patient 2 was deemed unstable due to deterioration of health status. The POC was finalized on 6/11/25 and did not indicate that a social worker was present during the IDT meeting. Patient 3 did not have POC developed for May and July 2025. During a concurrent interview and record review on 8/13/25 at 12:50 p.m. with the Clinical Coordinator (CC), the CC stated, “ ...For social worker, they have psychological status and transplant status of the patient ...We were kind of behind for [Patient 1] because we don’t have a social worker ...We found the coverage but it was overdue already for [Patient 1] ...” The CC confirmed Patient 2 and Patient 3 were deemed unstable and were expected to have a POC developed monthly. The CC also confirmed that there was no social worker present during the IDT meetings for Patient 2 and Patient 3 conducted in June 2025 and stated that if there was no signature on the POC, it meant the social worker was not present in the meetings. The CC confirmed Patient 2 did not have POC for July and August 2025 and Patient 3 did not have POC for May and July 2025. The CC stated that the facility did not have a social worker from June to July 2025 and stated, “ ...No one can do their assessment except for the social worker ...” During an interview on 8/13/25 at 1:59 p.m. with the Facility Administrator (FA), the FA stated, “ ...We know that we are overdue with the assessments ...The current social worker was working on catching up ...Psychosocial is important especially for diagnoses like AKI [Acute Kidney Injury - reversible kidney failure] and ESRD ...They have insights on how to support the patients with transplant ...” During a review of the facility’s policy and procedure (P&P) titled “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE,” revised 10/2024, the P&P indicated, “1. The facility’s interdisciplinary team (IDT) consists of, at a minimum ...a social worker ...2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care ...3. Assessment criteria will include, but not be limited to, evaluation of: ...Psychosocial needs by a social worker ...9. The plan of care will address, but not be limited to, the following: ...Psychosocial status which addresses necessary monitoring and social work interventions. Included are counseling services and referrals for other social services to assist patients in achieving and sustaining an appropriate psychosocial status ...14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative ...””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 48445 Based on observation, interview, and record review, the facility failed to ensure comprehensive assessments and plans of care were completed for two of seven sampled patients (Patient 1 and Patient 2) when: 1. No initial assessment and plan of care for Patient 1 after admission; and 2. No assessment and plan of care for Patient 2 after transfer and change in dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) modality. These failures had the potential to decrease the facility’s capability in identifying services necessary to address the patients’ needs. Findings: 1. During a review of Patient 1’s admission records, the records indicated Patient 1 was admitted to the facility in May 2025 with diagnosis of End-Stage Renal Disease (ESRD - irreversible kidney failure). During a concurrent observation and interview on 8/13/25 at 11:22 a.m. with Patient 1 in the treatment room, Patient 1 was observed sitting on dialysis chair undergoing dialysis via Arteriovenous fistula (AVF - a surgically created connection between an artery and a vein for use in dialysis) on left upper arm. Patient 1 stated she started dialysis two months ago, and dialysis was scheduled three times a week. During an interview on 8/13/25 at 12:22 p.m. with the Facility Administrator (FA), Patient 1’s plan of care was requested. The FA stated Patient 1 was newly admitted and did not have a plan of care yet and that the facility was still working on the 30 days assessment. During a concurrent interview and record review on 8/13/25 at 12:50 p.m. with the Clinical Coordinator (CC), the CC stated plan of care is developed within 30 days for new admissions and stated, “ ...If a patient was having dialysis for over a month in the facility, the expectation is that they already have a care plan ...” The CC confirmed Patient 1 was admitted in May 2025 and that there was no initial assessment and plan of care done for Patient 1. The CC further stated, “ ...We were kind of behind for [Patient 1] because we don’t have a social worker ...We found the coverage but it was overdue already for [Patient 1] ...the social worker was trying to catch up, maybe she missed [Patient 1] ...” During an interview on 8/13/25 at 1:59 p.m. with the FA, the FA stated, “ ...For new admissions, [plan of care] is done within 30 days, then reassessment in 90 days, and annually if stable ...” During a review of the facility’s policy and procedure (P&P) titled “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE,” revised 10/2024, the P&P indicated, “ ...10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines ...” 2. During a review of Patient 2’s admission records, the records indicated Patient 2 was admitted to the facility in January 2025 with diagnosis of ESRD. During a review of Patient 2’s Plan of Care (POC), dated 6/11/25, the POC indicated, “Reason: Transfer ... Modality: ICHD [In-Center Hemodialysis] ...” The POC further indicated Patient 2 was deemed unstable due to deterioration of health status. During a concurrent interview and records review on 8/13/25 with the CC, the CC stated Patient 2 was transferred to the facility in January 2025 from Home Hemodialysis (HHD - a way to perform dialysis at home instead of in a clinic) to ICHD. The CC confirmed Patient 2 did not have an initial assessment and POC upon transfer and that there was no other POC aside from the POC on 6/11/25. The CC further stated, “ ...important because that’s a change of modality, change of way she dialyzes from home to in-center, we want to see how she was coping with the change ...” During an interview on 8/13/25 at 1:59 p.m. with the FA, the FA stated, “ ...if modality change, assessed and POC developed in 30 days ...Important to do the assessment because it is a change in modality, it give us key insights on how the patient is responding to new modality ...” During a review of the facility’s P&P titled “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE,” revised 10/2024, the P&P indicated, “ ...16. Assessment and Plans of Care for Patients Transferring In: ...If the comprehensive Patient Assessment [PA] and Plan of Care for an experienced dialysis patient transferring from one facility to another is received with the patient in transfer and was completed by IDT in the last year, the IDT will review the PA/POC to determine that the documents reflect the patient’s current status and needs. If the documents are inadequate or if the patient is determined to be unstable, the patient would be assessed within the usual 30 days. If the documents are adequate and the patient is stable, the IDT may conduct a re-assessment within 3 months of admission. The IDT will meet within 15 days of completion of the reassessment, finalize the Plan of Care and initiate the plan ...Modality Change ...Within 30 days of change in modality (or within 13 treatments) ...””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 48445 Based on interview and record review, the facility failed to develop monthly plan of care (POC) for two of seven patients (Patient 2 and Patient 3) as required by the regulations for unstable patients. This failure had the potential to decrease the facility’s capability in addressing patients’ concerns and determining if these concerns were resolved. Findings: During a review of seven randomly selected patients’ POCs, reassessments were not completed and monthly POCs were not developed for the following two unstable patients: - Patient 2 was deemed unstable for deterioration of health status and the last POC was finalized on 6/11/25. There were no monthly POCs developed thereafter for Patient 2; and - Patient 3 was deemed unstable for deterioration of health status and the POC was finalized on 6/11/25 and 8/12/25. There was no POC developed in May and July 2025 for Patient 3. During a concurrent interview and record review on 8/13/25 at 12:50 p.m. with the Clinical Coordinator (CC), the CC stated that for unstable patients, plan of care should be done monthly. The CC confirmed Patient 2 did not have POCs developed for July and August 2025 and that the doctor was out for July and there was no social worker. The CC stated the POCs for Patient 2 were not finalized because the social worker assessment was not completed for July and August 2025. The CC also confirmed Patient 3 was deemed unstable on 4/16/25 and Patient 3’s POCs were developed on 6/11/25 and 8/12/25. The CC confirmed there were no POCs developed for Patient 3 for May and July 2025. The CC stated, “ ...Important because especially they are unstable, we discuss everything, to know if they are still unstable, and if improving, will be able to deem them as stable ...Expectation is it should have been done especially for the unstable patients ...” During an interview on 8/13/25 at 1:59 p.m. with the Facility Administrator (FA), the FA stated, “ ...We know that we are overdue with the assessments ...They [POCs] need to be done within 30 days for unstable patients ...” During a review of the facility’s policy and procedure (P&P) titled “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE,” revised 10/2024, the P&P indicated, “ ...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: ...At least monthly for unstable patients including, but not limited to, patients with the following: ...Marked deterioration in health status ...Monthly (unstable patients) ...Monthly until patient is determined by interdisciplinary team to be stable ...””

“PE-INCORPORATION BY REFERENCE CFR(s): (f) Incorporation by reference. The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, email fedreg.legal@nara.gov, or go to: www.archives.gov/federal__register/cfr/ibr-locations.html. If any changes in the editions of the Codes are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1-617-770-3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11 2011. (ii) TIA 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (2) [Reserved] This Standard is not met as evidenced by: 28347 Based on interview and observation, the facility failed to ensure the safety of its staff when two large printers were stored in front of the facility electrical panel. This failure had the potential to harm staff, emergency personnel, or power company employees as a result of the fall risk hazard. Findings: During an observation on 11/1/24, at 9:20 a.m., in the facility Electrical Room, two large printers were stored in front of the facility electrical panel. The placement of the printers impeded access to the electrical panel. During an interview on 11/1/24, at 9:20 a.m., with the facility Clinical Coordinator (CC), the CC stated that the printers should not be in the electrical room and that they were blocking access to the electrical panels. Per the NFPA 101, Life Safety Code, 2012 Edition 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NEC 70: National Electrical Code, 2011 Edition 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 38193 Based on interview and record review, the facility failed to ensure Patient 1 received the prescribed dose of dialysis when Patient 1’s treatment was shortened on 4/8/24. This failure had the potential to cause negative outcomes for Patient 1, up to and including death. Findings: During a review of the Treatment Details Report (TDS) for Patient 1, dated 4/8/24, the TDS indicated Patient 1 was prescribed a treatment duration of three hours and 15 minutes but was only provided a treatment duration of two hours and 58 minutes. There was no documentation explaining why Patient 1’s treatment was terminated early. During an interview on 11/1/24, at 11:20 a.m., with Facility Administrator 1 (FA 1), FA 1 stated that treatments should not be shortened without a valid reason and the reason should be documented in the patient record. FA 1 also stated that there was no documentation in the patient record explaining why Patient 1’s treatment was terminated early. During an interview on 11/1/24, at 11:35 a.m., with PCT 1, PCT 1 stated “We are supposed to provide the entire treatment that is prescribed. On 4/8/24 the treatment was shortened. No documentation was made to explain the reason for early treatment termination. During a review of the facility’s policy and procedure titled, Prescribed Treatment Time Not Met, dated April 2024, indicated, “...If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record...””

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by an obstructed fire extinguisher. This affected 79 of 79 patients and could result in the delay to responding to a fire in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 21.3.5.3 Portable fire extinguishers shall be provided in ambulatory health care facilities in accordance with 9.7.4.1.9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition 6.1.3.3 Visual Obstructions. 6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view. Findings: During an onsite investigation and interview with the Administrator on 10/29/24, the fire extinguishers were observed. At 3:36 p.m., a fire extinguisher mounted in a cubby on the wall next to the egress door near the Nurse Station on the treatment floor was observed. The fire extinguisher was obstructed by an evacuation kit. The evacuation kit was in a wheeled bin that measured approximately 36 inches long by 24 inches wide and by 24 inches tall. It was placed directly in front of the fire extinguisher, obstructing access. Upon interview, the Administrator acknowledged that the evacuation kit was obstructing the fire extinguisher.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 43380 Based on record review and interview the facility failed to ensure that all staff were familiar with the fire drill procedures. This was evidenced by missing fire drills records and failed to transmit signal during fire drill. This affected 79 of 79 patients and could result in staff being untrained and unaware of their roles and responsibilities in the event of a fire. Findings: During an onsite investigation, record review and interview with the Administrator on 10/29/24, the fire drill records were reviewed. 1. At 2:48 p.m., the facility failed to provide documentation that fire drills were conducted during the fourth quarter of 2023 and the first quarter of 2024. Upon interview, the Administrator stated that she had only been at the facility for a couple of months and acknowledged that they were missing fire drill records. 2. At 2:50 p.m., the facilities fire drill records indicated the fire drills were simulated, and the fire alarm system was not activated during the drills on 4/23/24 and 8/20/24. Upon interview, the Administrator acknowledged that the fire alarm was not activated during the fire drills.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage *Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. *Greater than 300 but less than 3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating. *Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the oxygen cylinder storage. This was evidenced by free-standing oxygen storage tanks and tanks that were not in an enclosure of non-or limited- combustible construction. This affected 79 of 79 patients and could result in damage to the oxygen storage tanks and increased risk of fire. NFPA 99: Health Care Facilities Code, 2012 Edition 11.3 Cylinder and Container Storage Requirements. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1)Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2)Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3)Cylinders shall be protected from tampering by unauthorized individuals. (4)Cylinders or cylinder valves shall not be repaired, painted, or altered. (5)Safety relief devices in valves or cylinders shall not be tampered with. (6)Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7)A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8)Sparks and flame shall be kept away from cylinders. (9)Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10)Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11)Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12)Cylinders shall not be supported by radiators, steam pipes, or heat ducts. 11.6.5 Special Precautions - Storage of Cylinders and Containers. Findings: During an onsite investigation and interview with the Administrator on 10/29/24, the oxygen storage area was observed. 1. At 2:38 p.m., the oxygen tank storage area behind the Nurse Station on the patient treatment floor was observed. Two of 20 E size oxygen were observed free standing on the floor and were not properly chained or supported by a stand or cart. Upon interview, the Administrator acknowledged that the tanks were not properly secured. 2. At 2:39 p.m., Approximately 20 full E type oxygen tanks (approximately 500 cubic feet) were observed near the Nurse Station on the patient treatment floor. The tanks were not stored within an enclosed interior space of non- or limited- combustible construction, with door that are secured. Upon interview, the Administrator acknowledged that the tanks were not properly stored in enclosure.”