Hale County Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46290 Based on medical record (MR) review, hospital policy and procedures, and staff interview, it was determined the hospital failed to ensure nineteen of thirty patients were informed of the patient’s rights and responsibilities prior to receiving care at the hospital. This had the potential to negatively affect all patients served by this hospital. Findings include: Hospital Policy: Patient Rights and Responsibilities Policy and Procedure Policy Number: None Listed Reviewed Date: 10/26/24 ...Purpose: To define and communicate the rights and responsibilities of patients receiving care... and to ensure all staff uphold these rights in accordance with legal and ethical standard. ...4. Documentation: Acknowledgement of receipt of Patient Rights and Responsibilities is documented in the patient’s medical record. Review of the MR’s of Patient Identifier (PI) # 2, PI # 4, PI # 5, PI # 7, PI # 8, PI # 9, PI # 10, PI # 12, PI # 13, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, and PI # 30 revealed there were no verbal or signed patient rights completed. An interview was conducted on 6/18/25 at 1:30 PM with Employee Identifier (EI) # 3, Director of Nursing, who confirmed the staff failed ensure the patients were informed of the patient’s rights and responsibilities prior to receiving care at the hospital.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41623 Based on medical record (MR) review, hospital policies and procedures, and interviews with staff it was determined the hospital failed to ensure: 1. Wounds were assessed and measured per hospital policy. 2. Wound care was provided per physician’s orders. 3. Physician was notified of new wounds. This deficient practice affected two of five patients with wounds including Patient Identifier (PI) # 8, and PI # 7, and had the potential to affect all patients with wounds admitted to this hospital. Findings include: Hospital Policy: Wound Care Policy and Procedure Policy Number: Not Listed Reviewed: 1/8/24 Policy Statements: 1. A patient and wound assessment must be completed and documented within 24 hours of admission... 2. A wound assessment must be completed and documented with every dressing change... 3. Wound assessments include: ...c. wound size including the longest length, widest width, and deepest depth... 4. Perform a wound assessment with every dressing change: a. Clean wound prior to assessment. b. Take wound measurements on admission, at least once a week (every seven days)... 1. PI # 8 was admitted to the hospital Swing Bed on 6/2/25 with diagnoses including Parkinson’s Disease, Abnormal Gait, and Asthenia. Review of the physician’s order dated 6/2/25 revealed orders for wound care to the right ankle and left heel every 48 hours. Cleanse wound with saline, cover with Hydrofera Blue, apply gauze, and wrap with Kerlix. Further review of the physician’s order dated 6/2/25 revealed orders to measure wounds on initial observation and every seven days. Review of the nursing documentation dated 6/3/25 revealed the nurse documented the presence of a vascular ulcer to the left ankle. The nurse further documented the wound was cleansed and dressing applied. There was no documentation of wound measurements of the new wound. There was no documentation the nurse notified the physician of the new wound and no documentation of a physician order for wound care to the left ankle. Further review of the nursing documentation on 6/2/25 revealed the nurse documented the presence of a Stage 2 venous stasis ulcer to the left heel and a Stage 2 pressure ulcer to the lateral right ankle. There was no documentation the wounds were measured on admission to Swing Bed and no documentation the wounds were measured every seven days. An interview was conducted on 6/18/25 at 11:30 AM with Employee Identifier (EI) # 1, Administrator, who confirmed the wound care was provided without a physician’s order and wound measurements were not obtained per hospital policy. 2. PI # 7 was admitted to the Swing Bed unit on 6/13/25 with diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and Cellulitis of Lower Leg. Review of the Wound Care Flow Sheet dated 6/14/25 revealed the nurse documented a new Stage 2 Pressure Ulcer between the gluteal folds. The wound was cleansed, skin protectant, and Mepilex dressing applied. There was no documentation the physician was notified of the new wound and no documentation of a wound care order. An interview was conducted on 6/18/25 at 11:42 AM with EI # 1 who confirmed the staff failed to notify the physician of the new wound and provided wound care without a physician’s order.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 41623 Based on medical record (MR), hospital policy, and interviews with staff, it was determined the hospital failed to ensure orders for wound care were complete. This deficient practice did affect two of five patients with wounds including PI (Patient Identifier) # 7, and PI # 18 and had the potential to affect all patients admitted to this hospital. Findings include: Hospital Policy: Wound Care Policy and Procedure Policy Number: Not Listed Reviewed: 1/8/24 ...Standards of Care: ...Wound care orders: All wound care orders must be complete in that they list: 1. Frequency of dressing change 2. Cleaning solution used in wound care procedure 3. Type of dressing to use... 4. Type of securement needed... 1. PI # 7 was admitted to the Swing Bed unit on 6/13/25 with diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and Cellulitis of Lower Leg. Review of the Wound Care Flow Sheet dated 6/14/25 revealed the nurse documented the presence of a Stage 2 Pressure Ulcer between the gluteal folds and wound care was provided including cleansing the wound and applying Mepilex dressing. There was no documentation of a physician order for wound care to the gluteal folds. Review of the Physician’s Order dated 6/17/25 revealed orders for wound care every three days, clean with Vashe, apply Mepilex now. There was no documentation in the physician’s order of the location of the wound. An interview was conducted on 6/18/25 at 11:42 AM with Employee Identifier # 1, Administrator, who confirmed the wound care order was not complete. 46293 2. PI # 18 was admitted to the hospital on 2/6/25 with diagnoses including Altered Mental Status, Gangrenous Pressure Injury Sacrum, and Sepsis. Review of the Wound Care Flowsheet revealed wound care was documented on 2/6/25 at 6:25 PM and 2/7/25 at 11:30 AM. Review of the physician’s order dated 2/07/25 revealed, Measure Wound on Initial Observation and Every Seven Days- Document Not Due on Days Other Than Initial and 7th. There was no physician’s order for the wound care provided. An interview was conducted on 6/18/25 at 1:25 PM with EI # 3, Director of Nursing, who confirmed there was no documentation of a physician’s order for the wound care provided.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 46290 Based on observations, hospital policy and procedures, and interview, it was determined the Dietary Director failed to ensure staff followed the policy and procedure for checking freezer temperatures and record actions taken when above zero degrees Fahrenheit (F). This had the potential to affect all patients admitted to the hospital. Findings include: Hospital Policy: Food Storage Temperature Logs Policy Number: DS.IV-16 Policy Reviewed: 6/12/24 Purpose: In order to prevent food borne illnesses, foods should be stored at proper temperatures... Process: ...b. Action should be taken and noted if temperatures are not in the recommended ranges: ...Freezers -10 to 0 degrees F. A tour of the dietary department was conducted on 6/16/25 at 10:25 AM with Employee Identifier (EI) # 5, Dietary Director. Review of the freezer temperature logs for the months of January 2025 to June 2025 revealed freezer temperature readings were out of range in the PM (afternoon) without notification of actions taken, as follows: January 1st to 31st, three days were recorded with temperatures of 8 degrees F, one day 10 degrees F and four days 18 degrees F. February 1st to 28th, five days were recorded with temperatures of 8 degrees F, and four days 10 degrees F. March 1st to 31st, nine days were recorded with temperatures of 8 degrees F, and 12 days with 10 degrees F. April 1st to 31st, three days were recorded with temperatures of 8 degrees F, two days with 9 degrees F and two days with 10 degrees F. May 1st to 31st, five days were recorded with temperatures of 8 degrees F, nine days with 10 degrees F, three days with 11 degrees F, and one day with 12 degrees F. June 1st to 16th, six days were recorded with temperatures of 8 degrees F and four days with 10 degrees F. An interview was conducted on 6/16/25 at 11:00 AM with EI # 5, who confirmed the staff failed to follow the hospital policy for checking freezer temperatures and note actions taken when above zero degrees F.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 46293 Based on observation, hospital policy and procedure and staff interviews, it was determined the hospital failed to ensure expired or opened sterile supplies were not available for patient use. This had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Management of Expired Supplies Review Date: 09/21/2024 Policy Number: None Policy Statement: It is the policy of Hale County Hospital to ensure expired medical and non-medical supplies are identified, removed, documented and disposed of promptly and safely in accordance with hospital protocols, manufacturer guidelines, and regulatory requirements to prevent patient harm. Procedure: 1. Routine Checks - Designated staff will inspect supply areas monthly. - Expired items will be ... removed immediately... 1. A tour of the Emergency Department was conducted on 6/16/25 at 10:00 AM with Employee Identifier (EI) # 6, Registered Nurse (RN). Located in the Trauma Room the following supplies were observed expired and available for use: a. Lumbar Puncture Tray with an expiration date of 9/30/24. b. Argyle Trocar Catheter 20 French with an expiration date of 7/31/24. c. Two Argyle Trocar Catheters 32 French with an expiration date of 7/31/24. An interview was conducted on 8/16/25 at 11:00 AM with EI # 6 who confirmed the items listed were expired and available for use. 2. A tour of the Medical-Surgical (Med-Surg) Unit was conducted on 6/16/25 at 10:12 AM with EI # 2, Infection Prevention Coordinator. An observation of the supply room revealed the following items expired or open and available for patient use. a. One Smith Medical Pro-Vent Arterial Blood Sampling Kit with an expiration date of 2/28/24. b. Two Becton Dickinson (BD) Insite Autoguard 18 g (gauge) x (by) 1.16 inch intravenous (IV)catheters with an expiration date of 9/30/24. c. Two Cardinal Health IV Start Kits labeled as contents sterile, open and available for patient use. EI # 2 confirmed at the time of the observation, the items were expired and the two IV start kits were open and all were available for patient use. An observation of the Utility Room revealed: a. Three iClean Sample Collection Kits with an expiration date of 3/26/25. EI # 4, Med-Surg RN, confirmed at the time of the observation, these items were expired and available for patient use. 41623”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 46290 Based on review of the personnel files, and interview with staff, it was determined the hospital failed to ensure the staff received training on Emergency Preparedness (EP) a minimum of every two years. This affected two of five hospital employees and one of one contracted staff personnel files reviewed and had the potential to affect all patients served by the hospital. Findings include: Review of the personnel files provided revealed no documentation the hospital employees and contracted staff completed EP training every two years. An interview was conducted on 6/18/25 at 1:48 PM with Employee Identifier (EI) # 1, Administrator, who confirmed the hospital failed to ensure staff received EP training at a minimum of every two years.”

“. K3 Building: 0101 K6 Plan Approval: 1962/1981/2004 K7 Survey Under: 2012 Existing K8 HOSP Generators: Two Diesel, One Kohler 60 kW (installed 12/2010) / One Olympia 100 kW (installed 07/2004) both have a remote manual stop station FACP: Honeywell S3 Series (installed 10/2021) Locking Devices: None Smoke Detection: Only at smoke doors Beds: 39 Census: 8 Type of Structure: 1962/1981/2004 one story unprotected noncombustible, Type II (000). The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 416.44(b) were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, Table 14.3.1(9)(h) This deficiency affects all smoke detectors. Findings include: During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to install quick-response sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1) 2010 NFPA 13, 8.3.3.2, and 8.3.3.4 This deficiency affects 1 of 5 smoke compartments. Findings include: During a tour of the facility, the surveyor observed one quick-response sprinkler head installed in the same compartment (Emergency Department Room 3) with one standard-response sprinkler head. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Supervisory Signals CFR(s): NFPA 101 Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to provide a NFPA approved tamper switch (electronic supervisory signal) for the automatic the sprinkler system valve per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.2.1 2010 NFPA 72, 10.16.2 This deficiency affects the whole facility. Findings include: During a tour of the facility, the facility failed to provide a supervisory tamper switch for one of the two valves in the automatic sprinkler pit. The other valve was supervised by the post indicator. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 41792 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.3 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2003 fast-response sprinklers found throughout the facility had been replaced or had a representative sample test completed within 20 years of installation. A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3 2010 NFPA 110, 8.3.7.1 This deficiency affects 2 of 2 generators. Findings include: During a tour of the facility, the facility failed to provide documentation of performing monthly testing and recording, of the electrolyte or conductance, of the batteries in both of the facility’s emergency generators for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“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. >300 but <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 hr. 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: 41792 . Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.5.4 This deficiency affects all of the back-up oxygen cylinders. Findings include: During a tour of the facility, the facility failed to protect the outside back-up oxygen cylinders in the storage area against continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified.”