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Based on observation and interview, the facility failed to ensure implementation of a sanitary environment to include separation of clean and sterile patient supplies from contaminated supplies in the Radiology Department, Nuclear Medicine Department, Emergency Department, Pharmacy, Laboratory; and Storage room.

The findings included:

Observations made with the Manager of Radiology and/or the Administrator during the facility tour on March 13, 2012, between 1:10 p.m. and 3:45 p.m., revealed the following:

Radiology Department - a table covered with a plastic table cloth, a small refrigerator, and a microwave oven, which were identified as a "staff eating area" located in the same area as portable X-Ray equipment and X-Ray plates; and a 2 cabinets and seven drawers containing patient care items along with papers, manuals, staff purses, staff food, and department decorations.

Nuclear Medicine Department - a Styrofoam container was situated on the floor in the Stress test area which contained numerous ? pints cartons of milk intended for patient use; and blood pressure cuffs for patient use were located in a drawer with manuals and papers.

Emergency Department - numerous drawers and cabinets at the nurse's station which contained patient use items such as blood pressure cuffs, paper measuring tapes, individually packaged Electro-Cardiogram (EKG) placement electrodes, EKG lead wires, individually packaged skin preps, stethoscopes, scissors, hemostats, and rolls of medical tape which were located in the same drawers and cabinets with such items as staff purses, staff hand lotion, office supplies, manuals, ink stamp printer, pens, markers, and magazines.

Pharmacy - (located in the ED medication room) located in a drawer were nine (named) injector devices (utilized to place in pre-drawn injectable medications and needle into the holder in order to ready the medication for patient intramuscular injections) with brownish specks on the devices, and located in drawer was one pill splitters with a rusty blade and one pill splitter with a white powder in the pill placement location on the pill splitter device.

Laboratory - located in the patient supply storage area containing supplies intended for patient use were two areas of a wall with hooks with several lab coats hanging from the hooks which were labeled "clean" and "dirty" above the respective hooks.

Storage room - located in the room were files, X-Ray films, various items of broken hospital equipment, boxes, a child crib with a plastic cover on the mattress, and an infant incubator which was turned on for warming to be ready for use.

Interview in the conference room with the Administrator on March 13, 2012, at 4:20 p.m., confirmed the patient supplies are to be stored separate from all unclean supplies; staff personal items are not to be stored with patient supplies; and the container of milk was not to be on the floor.