Pennsylvania Department of Health
 CLIVEDEN NURSING AND REHABILITATION CENTER
Building Inspection Results

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

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CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on June 22, 2026, at Cliveden Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73
 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 330402Component 01Main Building  Based on a Medicare/Medicaid Recertification Survey completed on June 22, 2026, it was determined that Cliveden Nursing and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a). This is a three-story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on documentation review and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents, affecting the entire facility. Findings include: 1. Document review on June 22, 2026, at 9:00 a.m., revealed the facility did not have approved Department of Health drawings/plans available for a new Nurse Call Bell System that had been installed on the First and Third floors. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the facility failed to obtain Department-approved plans prior to installation. 28 Pa Code 51.3. Notification (d)
 Plan of Correction - To be completed: 08/10/2026

The facility installed a new call bell system on 1st and 3rd floors in September 2025

All details will be submitted to Plan review

NHA or designee will in-service Maintenance staff on the importance of notifying DOH prior to initiating modifications and changes to cosmetic work and upgrade of any equipment
NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161 Based on document review and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility. Findings include: 1. Document review on June 22, 2026, at 9:00 a.m., revealed the facility was classified as a three story, Type II (000), unprotected ordinary building, with a basement, that was fully sprinklered. The building height exceeds the maximum allowance for this construction type by two stories. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the building construction lacks a fire resistance rating.
 Plan of Correction - To be completed: 08/10/2026

 The facility requests Department Health conduct an FSES for this deficiency
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain stairways, affecting two of four levels. Findings include: 1. Observation on June 22, 2026, between 11:15 a.m. and 12:15 p.m., revealed deficiencies at the following locations: a. 11:15 a.m., Electric Bike was stored inside stair tower, Lower Level near Business Office File Room. b. 12:15 p.m., Door failed to close and latch when tested, on the first floor, Stair Tower at Front Lobby. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the above deficiencies.
 Plan of Correction - To be completed: 08/10/2026

 - The electric bike has been removed.
- The door at the first-floor stair tower in the lobby has been repaired
- The maintenance team has conducted a full facility wide assessment, and no other broken doors or improper storage was noted.
- Facility Educator or designee will In service staff on the importance of not storing items in the stair towers.
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI
NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting two of four levels. Findings include: 1. Observation on June 22, 2026, between 11:15 a.m. and 12:20 p.m., revealed deficient battery back-up lights at the following locations: a. 11:15 a.m., lights failed to turn off, Lower-Level Stair Tower near Business Office File Room. b. 11:30 a.m., lights failed to illuminate when tested, Boiler Room near back door. c. 12:20 p.m., lights failed to illuminate when tested, Corridor near room 207. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the deficient back-up lights.
 Plan of Correction - To be completed: 08/10/2026

 Battery backup lights have been replaced at:
- Lower-level stair tower near Business office file room
- Boiler room near back door
- Corridor near 207
- The maintenance team has conducted a full facility wide assessment, and there were no other malfunctioning back-up batteries.
- Administrator or designee will In service the maintenance team on the importance of checking to ensure proper functioning of back –up batteries in all locations
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324 Based on observation and interview, it was determined the facility failed to ensure kitchen staff were trained on how to manually activate the kitchen cooktop fire suppression system, affecting one of four levels. Refer to NFPA 101 2012 Edition, Section 19.3.2.5.3(5b). Findings include: 1. Observation made on June 22, 2026, at 12:00 p.m., revealed two kitchen staff members did not know where the kitchen fire suppression system manual pull station was located when asked. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed kitchen staff personnel did not know the manual pull station location.
 Plan of Correction - To be completed: 08/10/2026

The two kitchen staff members were educated and now both know where the kitchen fire suppression system's manual pull station is located.
Maintenance Director or designee will Inservice all dietary staff to ensure they know the location of the kitchen fire suppression system's manual pull station
Maintenance Director or designee will conduct random "on the spot checks" with dietary staff to ensure all are aware and remember the location of the kitchen fire suppression system's manual pull station, weekly x 4 weeks
Results will be reported on monthly QAPI

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting two of four floors. Findings include: 1. Observation on June 22, 2026, between 11:55 a.m. and, revealed corridor doors that failed to close and latch when tested at the following locations: a. 11:50 a.m., Dining Room, left side door that enters the kitchen. b. 11:55 a.m., Dry Storage Room, Kitchen. c. 12:40 p.m., Bathroom, on the third floor, near Nurses Station. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the doors failed to close and latch.
 Plan of Correction - To be completed: 08/10/2026


The following doors have been repaired and all now close and latch properly:

- Dining Room left kitchen door
- Dry Storage Room kitchen door
- Bathroom door near 3rd floor nursing station
- The maintenance team has conducted a full facility wide assessment, and there were no other malfunctioning doors.
- Administrator or designee will Inservice the maintenance team on the importance of checking to ensure proper functioning doors in all locations
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of four levels. Findings include: 1. Observation on June 22, 2026, at 10:10 a.m., revealed an unsealed penetration surrounding data wires, above double smoke doors near room 120. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the unsealed penetration.
 Plan of Correction - To be completed: 08/10/2026

 - The unsealed penetration at the double smoke doors near room 120 has be sealed with W-L-3001 Fire Rated sealant.
- The maintenance team has conducted a full facility wide assessment, and there were no other penetrations noted
- Administrator or designee will In service the maintenance team on the importance of checking to ensure all penetrations are sealed with appropriated fire rated sealant
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI

NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521 Based on observation and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system, affecting three of four levels. Findings include: 1. Observation on June 22, 2026, between 11:50 a.m. and 12:45 p.m. revealed portable AC units that were vented directly into the ceiling, creating a plenum at the following locations: a. 11:50 a.m., Cafon the first floor b. 11:55 a.m., Kitchen c. 12:00 p.m., Nurses Station on the first floor d. 12:20 p.m., Corridor near room 206 e. 12:25 p.m., Corridor near room 214 d. 12:35 p.m., Nurses Station on the second floor f. 12:50 p.m., Nurses Station on the third floor Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the above deficiencies.
 Plan of Correction - To be completed: 08/10/2026

 - All HVACs will be properly vented to outside. Any HVAC that cannot be properly vented to outside will be removed.
- Maintenance team conducted a tour of facility and there were no additional HVACs installed improperly.
- administrator or designee will In-service the maintenance team on the importance of insuring all HVACs are properly ducted
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of chute discharge rooms, affecting one of four levels. Findings include: 1. Observation on June 22, 2026, between 11:40 a.m. and 12:35 p.m., revealed chute deficiencies at the following locations: a. 11:40 a.m., Excessive laundry bags in chute and in laundry cart, prohibited chute door from closing and latching, Lower-Level Laundry Chute Room. b. 12:30 p.m., Trash chute door failed to close and latch, Linen Chute Room on the second floor. c. 12:35 p.m., Trash chute door failed to close and latch, Linen Chute Room on the third floor. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the chute deficiencies.
 Plan of Correction - To be completed: 08/10/2026

 - Excessive laundry bags removed
- 2nd floor trash chute door has been repaired
- 3rd floor linen chute door has been repaired
- The maintenance team has conducted a full facility wide assessment, and there were no other chute deficiencies noted
- Administrator or designee will In service the maintenance team on the importance of checking to ensure all chutes are properly maintained and doors latch as designed.
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting one of nine generator reports. Findings include: 1. Document review on June 22, 2024, at 9:00 a.m., revealed the facility could not produce documentation of the 3-year, 4-hour Load Bank Test. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 08/10/2026

The emergency generator 3 yr, 4-hr load bank test has been completed effective __
- The maintenance team has conducted a review of the emergency generator test and load bank requirements. All others have been conducted and are on file in the facility
- Administrator or designee will Inservice the maintenance team on the importance of checking to ensure all required generator testing is conducted timely and kept on file
- Maintenance Director and/or team will conduct a review of generator requirements to ensure all have been conducted and results are on file in facility, monthly for 3 months
- Results will be reported in monthly QAPI
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of four levels. Findings include: 1. Observation on June 22, 2026, at 11:30 a.m., revealed two unsecured oxygen cylinders, Lower Level Oxygen Storage Room. Exit interview with the Administrator and the Maintenance Director on June 22, 2026, at 1:30 p.m., confirmed the unsecured cylinders.
 Plan of Correction - To be completed: 08/10/2026

 - The two unsecured oxygen cylinders have since been secured.
- The maintenance team has conducted a full facility wide assessment, and there were no other unsecured oxygen cylinders.
- Facility Educator or designee will Inservice staff on the importance of oxygen cylinders being secured and stored in the proper location.
- Maintenance Director and/or team will conduct facility rounds weekly x 4 weeks to ensure compliance in all areas.
- Results will be reported in monthly QAPI



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