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Based on staff interview, observation, and policy and procedure review the facility failed to maintain a clean and sanitary environment to avoid sources of transmission of infections on two (2) of two (2) days of survey.

Findings Include:

Observation of Room #1 of the Catherization Lab on 01/19/2022 at 3:45 p.m. revealed three (3) large biohazard needle containers on the floor with open lids, one (1) ¾'s full and two (2) transfer boards on the floor leaning against the wall behind the biohazard needle containers. The floor and pedestal base around the catherization table had a white substance with a large amount of dirt adhered to the substance.

Interview with Infection Prevention Director during the tour of the catherization lab on 01/19/2022 at 3:45 p.m. confirmed the open needle containers, transfer boards on the floor, and dirty area around the pedestal and floor of the catherization table.

Review of Policy and Procedure for "Procedural Room Cleaning" No policy number; effective date 04/04/2016; no approval or review/revision dates, reveals; " ...Remove all used ...3/4 full sharps containers, soiled equipment and items for reprocessing if applicable..." " ...Clean and disinfect: ... the floor inside the procedure field ...".

During Exit Conference at 2:00 p.m. on 01/20/2022 findings were discussed and no further documentation was submitted for review.