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Based on observations and staff interviews, the facility failed to ensure access to one exit was marked with an approved, readily visible sign where the exit or way to reach the exit was not readily apparent, in accordance with the code at 7.10.1.4. This affected 1 of 3 exit access doors in the in-patient therapy gymnasium on the second floor. The facility has a total of 40 beds and a census of 29 on the first survey day on 02/25/13.

Findings include:

On 02/25/13, between 1:30 PM and 4:10 PM, a tour was conducted of the facility with Staff B, D, and E.

During the tour, observations revealed three exit access doors in the second floor in-patient therapy gymnasium. Two of these doors were equipped with an approved illuminated exit sign which was readily visible. The third exit was observed located by the therapy offices, and an equipment room, at the end of a 7 feet long by 6 feet wide alcove. An illuminated exit sign was observed located above the exit access door,; however, this sign was not readily visible from the gymnasium. The sign was only visible upon entrance into the alcove. This gymnasium was observed with exercise equipment, tall ceilings, and was approximately 1900 square feet in diameter.

During tour, Staff B and D verified this exit sign, located above the exit access door, was not readily visible from inside the gymnasium. These staff also verified staff, visitors, and patients could easily enter into the offices or equipment room in the event of a fire and smoke.

The lack of these exit signs was verified by Staff AA on tour. This employee stated these exit access doors were designated exits and should have exit signs in place.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubic feet of oxygen, (over 12 E-tanks), was stored in accordance with NFPA 99, 4.3.1.1.2. This involved one of four smoke compartments in the facility. This has the potential to affect all patients, staff, and visitors on the A East Unit. The facility has a total of 40 beds and a census of 29 on the first survey day on 02/25/13.

Findings include:

On 02/25/13, between 1:30 PM and 4:10 PM, a tour was conducted of the facility with Staff B, D, and E.

Findings include:

During tour of the A East wing, the clean utility room, located near the day room, was observed with nine E-sized and seven D-sized cylinders filled with oxygen, for a total of 321 cubic feet of oxygen. In the same smoke compartment, an additional E-sized tank of oxygen was observed on the crash cart located at the nurses' station. The total amount of oxygen stored in the smoke compartment was 345 cubit feet of oxygen. The clean utility room was located in the main egress corridor, and lacked a fire rated door to the corridor.

On 02/25/13, during the tour, an interview conducted with Staff B verified the amount of oxygen and the location of the oxygen stored in this smoke compartment.

Based on observations and staff interviews, the facility failed to ensure a non-smoking sign was located on the one oxygen storage room on the A East hallway, in accordance with 19.3.2.4 and NFPA 99, 8.6.4.2. This has the potential to affect all patients, staff, and visitors on the A East unit. The facility has a total of 40 beds and a census of 29 on the first survey day on 02/25/13.

Findings include:

On 02/25/13, between 1:30 PM and 4:10 PM, a tour was conducted of the facility with Staff B, D, and E.

Findings include:

During a tour of the A East wing, the clean utility room, located near the day room, was observed with nine E-sized and seven D-sized cylinders filled with oxygen. The doorframe and door lacked a sign stating no smoking, oxygen storage. The sign was located on the metal doorframe inside the room. When the surveyor shared this observation with Staff B, this employee was observed placing the sign on the outside of the door on the metal doorframe. According to an interview with Staff B, at the time of the tour, this room was routinely used for oxygen storage.

Based on observation of the A East wing, and staff interviews, the facility failed to ensure compliance with NFPA 70, 110-3(b) and 400-7(b) in regard to power strips. This affected one area of the facility on the A East wing, and has the potential to affect all patients, staff, and visitors in the facility. The facility has a total of 40 beds and a census of 29 on the first survey day on 02/25/13.

Findings include:

On 02/25/13, between 1:30 PM and 4:10 PM, a tour was conducted of the facility with Staff B, D, and E.

The tour revealed at the A East nursing station two power strips daisy-chained together. Beginning from the wall, the first power strip had receptacles occupied with computer monitoring equipment and a copier, and the last receptacle in use by the second power strip. The second power strip had four receptacles in use by office equipment which included a stapler and pencil sharper.

On 02/25/13, during tour, this observation was confirmed with Staff B, D, and E.