Deerfield Episcopal Retirement: Oxygen Tank Left Unsecured - NC
Federal inspectors documented the finding on June 2, 2026. The resident, identified in inspection records as Resident 28, depends on supplemental oxygen. When she leaves her room, staff connect her to a portable tank mounted in a fabric holder on the back of her wheelchair. When she returns, they either switch her to the room's oxygen concentrator or leave her on the portable tank. The rolling cart in her room exists specifically to keep those portable tanks secured upright when not in use.
On the morning of the inspection, the tank was not in the cart. It was not attached to the wheelchair. It was leaning against a piece of furniture, between a quarter full and empty.
The Director of Nursing was in the room when inspectors made the observation. She looked at the tank against the filing cabinet and said that was not how oxygen tanks should be stored. She confirmed the rolling cart was right there in the room. She said she didn't know how this happened.
Two nursing assistants had worked that morning with Resident 28. The first, identified as NA 2, said she did not see any oxygen tank on the floor and that if she had, she would have put it back on the wheelchair holder or in the rolling cart. The second, NA 1, explained the general routine: portable tanks go in the fabric holder on the wheelchair when the resident is out of the room, and staff switch her to the concentrator when she gets back into bed. Neither reported noticing the unsecured tank.
The nurse assigned to Resident 28 said she had been in the room twice that morning, briefly around 9:15 and again around 10:30. She said she did not notice any oxygen tank in her line of sight either time.
The Director of Nursing noted that the night and day shift aides conduct walking rounds together at shift change, between 6:45 and 7:15 in the morning, and that the unsecured tank should have been caught then. It was not.
The administrator, interviewed the following morning, said the facility had not had problems with oxygen tanks before and called this a case of human error. He acknowledged the tank was under pressure and that if it had fallen or been bumped, there could have been safety consequences. He said the expectation was that tanks were properly secured at all times.
The Director of Nursing, in a follow-up interview on June 3, explained that oxygen tanks are supposed to be secured in a rolling cart or a bag on the wheelchair, and that full tanks are kept in a secure rack in the oxygen storage room. She said proper storage is covered with new staff during orientation. She was direct about the risk: oxygen tanks cannot be left outside the rolling cart, whether full or empty, because an unsecured tank is a safety hazard.
That part is not in dispute. Everyone interviewed agreed on what the procedure was. The tank that morning had not followed it.
Inspectors rated the violation as causing minimal harm or potential for actual harm, with few residents affected. The facility received no immediate jeopardy designation.
What the inspection record does not answer is how long the tank had been sitting there. Shift change rounds had passed. A nurse had been in the room twice. Two aides had worked the room. The tank was between a quarter full and empty when inspectors found it, which means whatever oxygen had been in it when it was last used had been quietly running down, or had already run out, while it leaned against the filing cabinet with no one the wiser.
Resident 28 was in her room when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deerfield Episcopal Retirement from 2026-06-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Deerfield Episcopal Retirement in Asheville, NC was cited for violations during a health inspection on June 4, 2026.
Federal inspectors documented the finding on June 2, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.