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Based on review of facility policy, observation, and staff interview (EMP), it was determined the facility failed to maintain and sustain a safe and sanitary environment in the decontamination and sterile processing rooms for the operating suite.

Findings include:

Review on February 9, 2016, of the facility's policies and procedures revealed there was no policy addressing the maintenance, safety and sanitation of the decontamination and sterile processing rooms. This was confirmed by EMP1.

An observation tour of the decontamination room and sterile processing area in the operating suite was conducted on February 9, 2016. The following issues were identified: The decontamination room floor was dirty with debris on the floor, including a sterile towel and 4x4's. The floor had numerous black spots and cracks. There were several large areas of rust noted at the base of the stainless steel counter. The ceiling had several large brown discolored spots from old leaks. The light lens was discolored with a large yellow area noted in the center.

The sterile processing room floor had dark black spots, and a large area of rust was noted around an oxygen tank stored in the corner of the room. The thermostat on the wall was secured with numerous layers of tape. There was a heavy accumulation of lime scale noted within the large autoclave. The room was cluttered, significantly reducing the walking space.

Interview with EMP2 confirmed the floors were buffed over the weekend, and the black areas did not come off. EMP2 confirmed the observations, including the yellow stains on the ceiling and the rust areas on the floor.