"Oxygen in Use signage should be posted to alert staff, visitors, and residents that oxygen was in use in the room to maintain safety and prevent potential fire hazards," the assistant told inspectors on December 23.
But no such signs appeared on the doors of residents receiving oxygen therapy.
Inspectors found the violation during a December complaint investigation. They observed Resident 3 lying in bed while receiving oxygen at 2 liters per minute through a nasal cannula on December 19. No warning sign marked his doorway.
The resident had an active physician order for oxygen therapy dated November 24, to be administered as needed for shortness of breath and comfort. Four days later, inspectors returned and found the same problem. No oxygen warning sign on his door.
Licensed Nurse 3 confirmed during the December 19 observation that Resident 3 was receiving oxygen for shortness of breath. The certified nursing assistant who spoke with inspectors four days later confirmed that Resident 3 was still receiving oxygen through a concentrator, but acknowledged no warning signage had been posted.
The facility's own policy, revised in September 2022, explicitly requires the safety measure. Under "Steps in the Procedure," the oxygen administration policy states: "Place an Oxygen in Use sign on the outside of the room entrance door."
The policy lists "No Smoking/Oxygen in Use signs" among required equipment and supplies. Its stated purpose is "to provide guidelines for safe oxygen administration."
The Director of Staff Development confirmed during a December 23 interview that nurses were responsible for posting oxygen warning signs when residents were receiving therapy. The purpose was to prevent fire hazards and meet residents' needs.
The Assistant Director of Nursing went further during her interview the same day. She explained that oxygen warning signs served as crucial safety precautions, alerting everyone entering the room that oxygen was in use.
"When there was an order for oxygen therapy, nurses were responsible to ensure oxygen in use signage was posted on the resident's doorway," she told inspectors.
The nursing director said she expected staff to post the signs immediately upon receiving and implementing oxygen orders. She acknowledged this expectation wasn't met.
The Assistant Director of Nursing stated it was necessary to post warning signs on both Resident 2's and Resident 3's doorways to alert staff, residents, and visitors about oxygen use and prevent fire hazards.
She admitted the facility's policy wasn't followed.
The violation affected multiple residents. Inspectors referenced both Resident 2 and Resident 3 in their findings, though the report provides detailed observations only for Resident 3's case.
Federal inspectors classified the deficiency as having minimal harm or potential for actual harm, affecting few residents. The violation fell under federal tag F 0695, which covers requirements for safe administration of oxygen therapy.
The inspection was conducted as a complaint investigation on December 23, 2025. The specific nature of the original complaint that triggered the federal review was not detailed in the inspection report.
Oxygen concentrators and nasal cannulas are common medical devices in nursing homes, used to deliver supplemental oxygen to residents with breathing difficulties. The therapy helps residents with conditions ranging from chronic obstructive pulmonary disease to heart failure.
Fire safety protocols around oxygen use are critical because oxygen supports combustion. Even small ignition sources like static electricity or faulty electrical equipment can cause serious fires in oxygen-rich environments.
The "Oxygen in Use" signs serve multiple purposes beyond fire prevention. They alert maintenance workers to avoid using electrical equipment that might create sparks. They remind visitors and staff not to smoke. They signal to emergency responders that oxygen tanks or concentrators are present.
Guardian Care and Rehabilitation Center is located at 410 Eastwood Avenue in Manteca. The facility was required to submit a plan of correction addressing how it would ensure proper posting of oxygen warning signs going forward.
The nursing director's acknowledgment that staff failed to meet basic safety expectations highlights a gap between written policies and daily practice. Despite having clear procedures in place since September 2022, nurses weren't implementing the most basic safety measure for oxygen therapy.
Resident 3 continued receiving his prescribed oxygen therapy throughout the inspection period, but without the warning signs that could have prevented a potential fire emergency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Guardian Care and Rehabilitation Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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