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NFPA 101, 2000 Edition
7.10.1.2 Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

19.2.10.1 Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system.

7.10.5 Illumination of Signs.
7.10.5.1* General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.


Based on observation and staff interview, the facility failed to ensure the laboratory suite exit access and exit access doors were labeled with directional signage to provide clear direction of travel to required exits. It is important the direction of travel to reach required exits is clearly labeled to avoid confusion in the event of emergency. This deficient practice had the potential of affect four (4) staff working within the laboratory suite. The findings are:

A. On 08/31/10 at 12:15 pm, during a tour of the facility with the Maintenance Director, the surveyor observed the laboratory suite was not provided with exit directional signage.
1. During interview at this time, the Maintenance Director stated he never noticed directional signage was not provided.
2. On 08/31/10 at 3:30 pm, the Administrator and the Maintenance Director, and several other facility Staff, acknowledged the above findings at exit conference.

Reference NFPA 99, Section 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).

Section 8-6.4.2 Signs. Precautionary signs, readable from a distance of 5 ft. shall be conspicuously displayed at the site of administration and in aisles and walkways leading to the area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.



Based on observation and staff interview, the facility failed to ensure storage of oxygen was in compliance with NFPA 99 (Standard for Healthcare Facilities). It is essential oxygen cylinders are stored upright in approved racks or secure in their holders to protect them from accidental damage or dislocation during handling. Oxygen cylinders are highly pressurized vessels; mismanagement could result in fire or accidental discharge. This deficient practice had the potential to affect those patients, staff, and occupants which use corridor C07 and C08. The findings are:

A. On 08/31/10 at 1:00 pm, during a tour of the facility with the Maintenance Director, the surveyor observed two (2) size "E" oxygen cylinders free standing within the respitory oxygen storage room located near dietary.
1. During interview at this time, the Maintenance Director stated he was unsure why the cylinders were not secured in a rack or in a holder.
2. On 08/31/10 at 3:30 pm, the Administrator and the Maintenance Director, and several other facility Staff, acknowledged the above findings at exit conference.